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U.5. 



Navy Medicine 



June 1976 



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VADM Donald L. Castis, MC, USN 

Surgeon General of the Navy 

RADM Charles L. Waite, MC, USN 

Deputy Surgeon General 

EDITOR 

Sylvia W. Shaffer 

MANAGING EDITOR 

June Wyman 

ASSISTANT EDITOR 

Virginia M. Novinsfci 

EDITORIAL ASSISTANT 

Nancy R. Keesee 

CONTRIBUTING EDITORS 

Contributing Editor-in-Chief: 
CAPT CM. Herman, MC, USN 
Aerospace Medicine: CAPTF.H. Austin, Jr. 
(MC); Dental Corps: CAPT E.E. McDonald 
(DC); Education: CAPT W.M. McDermott, 
Jr. (MC); Fleet Support: CAPT J.W. Johnson 
(MC); Gastroenterology: CAPT D.O. Castell 
(MC); Head and Neck: CAPT R.W. Cantrell 
(MC); Hospital Corps: HMCM H.S. 
Anderson; Legal: CDR C.A. Buhler 
(JAGC); Marine Corps: CAPT D.R. Hauler 
(MC) ; Medical Service Corps: LCDR J.T. 
Dalton (MSC); Naval Reserve: CAPT N.V. 
Cooley (MC, USNR); Nephrology: CDR J.D. 
Wallin (MC); Nurse Corps: CAPT B.G. 
Nagy (NC); Occupational Medicine: CAPT 
CM, Lawton (MC); Preventive Medicine: 
CAPT C.E. Alexander (MC); Psychiatry: 
CAPT R.E. Strange (MC); Research: CAPT 
C.E. Brodine (MC); Submarine Medicine: 
CAPT H.E. Glick (MC) 

POLICY: U.S. Navy Medicine is an official publication 
of the Navy Medical Department, published by the Bureau 
of Medicine and Surgery. It disseminates to Medical De- 
partment officers of the Regular Navy and Naval Reserve 
official and profess ion a I information relative to medicine, 
dentistry, and the allied health sciences, Opinions 
expressed are those of the authors and do not necessarily 
represent the official position of the Department of the 
Navy, the Bureau of Medicine and Surgery, or any other 
governmental department or agency. Trade names are used 
for identification only and do not represent an endorsement 
by the Department of the Navy or the Bureau of Medicine 
and Surgery. Although B>S, Navy Medicine may cite or 
extract from directives, official authority for action should 
be obtained from the cited reference. 

DISTRIBUTION: U.S. Navy Medicine is distributed to 
active-duty Medical Department officers via the Standard 
Navy Distribution List. Requests to increase or decrease the 
number of allotted copies should be forwarded to U.S. Navy 
Medicine via the local command. 

CORRESPONDENCE: All correspondence should be 
addressed to: Editor, U.S. Navy Medicine, Department of 
the Navy, Bureau of Medicine and Surgery (Code 0010), 
Washington, D.C. 20372. Telephone: (Area Code 202) 
254-4253, 254-4316, 254-4214; Autovon 294-4253, 294-4316, 
294-4214. Contributions from the field are welcome and will 
be published as space permits, subject to editing and pos- 
sible abridgment. 

The issuance of this publication is approved in accor- 
dance with Department of the Navy Publications and 
Printing Regulations (NAVEXOS P-35). 



NAVMED P-5088 



"■•■NAVY 

MEDICINE 



Volume 67, Number 6, June 1976 



1 From the Chief 

2 Department Rounds 

Protecting the Navy workplace . . . Coming up: NRMC Okinawa . . . 
Richard Jewell honored for work with alcoholics 

5 Hospital Corpsmen, Then and Now 
HMCS F.J. Scanlon 

6 Enlisted Scene 

Planning to reenlist? . . . Hoping to advance? . . . How to get "C" 
school training 

7 NAVMED Newsmakers 

8 Off Duty Mountain medicine . . . The sweet life 

10 On Duty Medical care in the Belknap-Kennedy collision 

13 Notes and Announcements 

Pacific area medical/dental liaison office directory . . . Ten-day option 
eliminated . . . Dental officer training requests . . . Occupational health, 
anesthesiology meetings . . . Trauma symposium . . . HQ Marine Corps 
medical conference . . . Sixth Asian-Pacific Cardiology Congress 

16 Soundings 

Division Officers/Leading Petty Officers: New Help for Hospitals 
HMCM T.G. Gardner, USN 

18 Policy Instructions and Directives 

21 Clinical Notes 

Propranolol in Migraine Prophylaxis 
LCDR R.C. Packard, MC, USN 

22 Professional 

Human Energy Requirements: A Simple Tool for Assessment in 
a Weight Control Program 
LT S.R. Lamar, MSC, USN 

26 Sublingual Dermoid Cyst: Report of a Case 
LCDR M.B. Smith, DC, USN 
CAPT B.J. DeVos, DC, USN 

28 Scholars' Scuttlebutt Tax Change Hits Students 

29 BUMED SITREP 

COVER: When the USS Belknap and the USS Kennedy collided last 
November, the mass casualty system was equal to the test — thanks to 
careful planning and countless practice drills. Our cover, by PHAN R. 
Wilborn, shows a patient being transferred from the Kennedy flight deck 
to the deck edge elevator. For a report of Navy medicine's response to 
this crisis at sea, turn to page 10. 



From the Chief 



Medical Care Evaluation Programs 




Photo by Pffi Terry Mitchell 



Delivery of health care in the modern 
environment is undergoing more scru- 
tiny and is being affected by more influ- 
ences outside the medical community 
than at probably any time in history. At 
the same time, the medical community 
itself is striving to improve the health 
care being given and to find ways to 
quantify these improvements objec- 
tively. In this latter regard the Joint 
Commission on Accreditation of Hos- 
pitals has implemented what are con- 
sidered standards for objectively eval- 
uating the patient care given in a health 
care institution; to encourage the use of 
these standards, the JCAH has made 
their use a significant factor in the ac- 
creditation process. 

On 1 March 1976, BUMEDINST 
6320.54, "Medical Care Evaluation Pro- 
gram for Regional Medical Centers and 
Hospitals," was published, setting 
forth the official Navy position for guid- 
ing our medical centers and hospitals as 
they develop their own internal medical 
care evaluation programs. In addition, a 
BUMED SITREP was released this 
month which amplifies the Bureau's 
policy regarding compliance with JCAH 
standards. In brief, this policy encom- 
passes three distinct but interrelated 
elements: 

• Patient care audit — Evaluation of the 
quality of patient care rendered. 

• Utilization review — Examination of 
efficiency in use of the institution and 
resources. 

• Credentialling — The procedure for 
processing and evaluating applicants 
for clinical staff membership, and 
granting of clinical privileges. 

These elements are purposely broad 
in scope and are intended to give wide 
flexibility for tailoring evaluation pro- 
grams within the constraints and pecu- 



liarities of the local center, as well as to 
encourage maximum effort in comply- 
ing with the JCAH standards. 

When this SITREP is received at our 
centers and hospitals, I urge that it be 
seen by all members of the clinical staff. 
One point stands out very clearly: The 
local program cannot be developed by 
any other source. It is essentially a local 
program to be developed, implemented 
and monitored by local staff clinicians. 
From a professional standpoint, partici- 
pation by local practitioners in the 
development of the local Medical Care 
Evaluation Program presents an ideal 
opportunity to affect the manner in 
which health care is being delivered at 
their hospital or center, I cannot stress 
strongly enough that the entire local 
staffs should be familiar with the ele- 
ments of the Medical Care Evaluation 
Program if their efforts are to be suc- 
cessful. 

Navy health care practitioners pro- 
vide services closely touching people's 
lives; they should be able to demon- 
strate to themselves and their patients 
that quality medical care is being pro- 
vided. Medical care evaluation is one of 
the management tools to do just that. 
Your support of the Navy's program is 
earnestly desired. 




Surgeon General of the Navy 



Volume 67, June 1976 



Department Rounds 



Navy medicine draws a bead on 



TCE, Asbestos, and a Host 
of Hazards 



If someone told you your coffee 
was decaffeinated with trichloro- 
ethylene (TCE), you'd probably go 
right on drinking. After all, when 
supermarket products overflow with 
chemicals, one more in your coffee 
is nothing to write home about. 

But you'd be wrong about TCE. 
Preliminary data shows that this 
photochemically reactive organic 
solvent is a potent liver carcinogen 
in laboratory mice and a possible 
cancer threat to humans. To protect 
Navy workers, BUMED recently 
issued a TCE alert. BUMED In- 
struction 6260.22 of 18 March 1976 
urges commands to substitute the 
less toxic methylchloroform (1, 1, 1- 
trichloroethane) or perchloroethane 
when a solvent is needed. Also, 
Navymen regularly exposed to TCE 
will be placed under medical sur- 
veillance; industrial hygienists will 
monitor their workplace for ade- 
quate engineering controls and use 
of personal protective gear such as 
respirators and clothing. 

TCE is no longer used to decaf - 
feinate coffee — but it is used for in- 
dustrial purposes. The Navy uses it 
mainly to degrease metal parts. 
Workers who inhale enough TCE 
vapor can experience disturbed 
vision, confusion, nausea and vom- 
iting. More serious consequences 
such as liver and kidney injuries 
have been attributed, although 
rarely, to TCE overexposure. 

The TCE monitoring program is 
one of many measures BUMED's 
Occupational and Preventive Medi- 
cine Division is taking to safeguard 
Navy workers' health. Commands 
are expected to begin annual work- 
place inspections of their own 
activities in FY77, supplemented by 



random checks by the Navy Inspec- 
tor General. The CNO's logistics 
section is establishing its own oc- 
cupational safety and health pro- 
gram under the direction of CDR 
James Groff, a civil engineer; his 
staff will include full-time occupa- 
tional health specialists. 




Family practice resident LT J. A. 
Schenk (MC), left, learns about noise 
problems aboard the USS Davis 

Besides helping set up the work- 
place inspection apparatus, BU- 
MED's occupational health staff has 
been deeply involved with new 
weapons systems and new ships. 
Says CAPT George M. Lawton 
(MC), Occupational and Preventive 
Medicine Division deputy director, 
"We're trying to work with weap- 
ons developers at an early stage to 
eliminate, or at least control, un- 
necessary occupational health haz- 
ards." Failure to get involved early 
can mean expensive delays in the 
work while safety devices are in- 
stalled. One example; workers ser- 
vicing the new Mark 48 torpedo 
showed toxic symptoms which were 
traced to the torpedo's propellant, 



Otto Fuel II. Development of the 
torpedo was held up while toxicol- 
ogy tests were done on the fuel and 
a ventilation system designed. To 
avoid similar problems in the fu- 
ture, Navy industrial hygienists are 
now testing propellants and exhaust 
products for the HERO, harpoon 
and cruise missile systems. Also, 
toxicology tests are performed on 
materials going into new ships; for 
instance, the Navy will test lubri- 
cants, fuels and general use con- 
sumables to be used on the new 
Trident submarine. 

Possible carcinogens other than 
TCE continue to involve BUMED's 
occupational medicine staff. The 
problem of asbestos drew national 
attention in 1975 when the Ameri- 
can Cancer Society criticized the 
Navy for not tracking down World 
War II shipyard workers who might 
have contracted mesothelioma or 
lung cancer from asbestos expo- 
sure. On the drawing board now is a 
proposal to study World War II 
Brooklyn Naval Shipyard workers, 
comparing the mortality of those 
who did and did not work with 
asbestos. The privately funded 
study would be conducted by a 
civilian investigator. One problem 
to be solved: the personnel records 
of civilian workers are virtually 
closed to non-federal medical re- 
searchers under the Privacy Act. 

Although no asbestos may be 
used in Navy ships built after 1 
January 1976 (manganese oxide 
materials or fiberglass insulation 
will be substituted), CAPT Lawton 
points out that there is still a lot of 
asbestos on Navy ships. BUMED 
and the CNO have issued several in- 
structions directing commands on 
asbestos control. 

In the mill is a detailed BUMED 
instruction on health monitoring of 
Navy jobs in which suspected car- 
cinogens are used. On a broader 
scale, the National Academy of 
Sciences is reviewing a number of 
military occupations for all kinds of 
health risk. Results are not ex- 
pected for at least two years. 

Hearing conservation is also re- 
ceiving close attention. The Sur- 



U.S. Navy Medicine 



geon General recently told com- 
manding officers to set up hearing 
conservation programs, and to 
make sure sailors use ear protec- 
tors. The Health Sciences Education 
and Training Command has 
mounted a campaign to educate 
Navy men and women about noise 
perils. And the Naval Aerospace 
Medical Research Laboratory, Pen- 
sacola is studying hearing loss 
among ten Navy ratings exposed to 
high noise levels. 

Although Navy occupational med- 
icine has made substantial prog- 
ress in eliminating health hazards 
aboard ship and at shore facilities, 
obstacles remain. Like everything, 
safety has its price tag. "Modifying 
a ship to conform with safety regu- 
lations is extremely expensive," 
says CAPT Lawton, "and removes 
the ship from operation for some 
time. Basic changes must be en- 
gineered for each ship individual- 
ly." 

Another roadblock: the future 
effect of on-the-job hazards is hard 
to take seriously today, CAPT 
Lawton says. "Everyone knows the 
dangers of cigarette smoking, but 
look at how many people still 
smoke. They're willing to take the 
risk." People often have too many 
immediate problems, he adds, to 
give much thought to preventing 
diseases that may or may not flare 
up in 30 years. CAPT Lawton 
advises Medical Department per- 
sonnel, often untrained in spotting 
occupation-related health problems, 
to get out of their office and into the 
workplace to see for themselves 
exactly what hazards their patients 
face. 

The key to eliminating hazards is 
safety awareness. If a corpsman 
sees that a shipboard machine gen- 
erates too much noise, he can mark 
the equipment with stickers, avail- 
able from naval supply points, that 
warn "Produces Hazardous Noise." 
Simple, inexpensive — and effective. 
A little propagandizing for on-the- 
job safety can go a long way, too. 
Workers don't usually risk their 
health deliberately — they are just 
unaware of the dangers. 




U.S. Army Hospital Kuwae, Okinawa: Going Navy 



Facilities 



Okinawa 
Transfer 



U.S. Army Hospital Kuwae, 
Okinawa will become Naval Region- 
al Medical Center Okinawa when 
the Navy takes over the 18-year-old 
hospital in FY77. 

The Navy Medical Department 
will also take over the Army's 
Makiminato dispensary and Evans 
dental clinic on Okinawa, and the 
Army regional medical laboratory at 
Sagami-Ono, Japan, 

The switchover is the result of a 
drop in the number of Army units in 
Japan and Okinawa, and the in- 
creasing dominance of the Navy and 
Marine Corps in the Western 
Pacific. 

Under the Navy, the hospital will 
become an independent regional 
medical center with regional dis- 
pensaries. Preventive and environ- 
mental medical activities will be 
carried out by a detachment of Pre- 
ventive Medicine Unit (PMU) 6 in 
Hawaii. The Sagami-Ono labora- 
tory will operate as part of Naval 
Regional Medical Center Yokosuka, 
Japan, under the direction of an 
officer-in-charge. 



The Okinawa hospital has an 
operating capacity of 350 beds and 
can expand to 700. Besides provid- 
ing a full range of specialty services 
for approximately 55,000 military, 
military dependents, and civilian 
personnel, the hospital also oper- 
ates the military's Western Pacific 
burn center and radioisotope labo- 
ratory. When the Navy takes over, 
the hospital is expected to have 35 
to 40 physicians. 

The Sagami-Ono laboratory 
serves as the Army's Pacific Com- 
mand blood bank and Western Pa- 
cific drug testing facility, and offers 
sophisticated services in pathology, 
toxicology, entomology, virology, 
bacteriology, parasitology and clini- 
cal chemistry. 

Okinawa's climate is semi-tropi- 
cal, with average temperatures 
from 52°F. in February to 90°F. in 
July; typhoons can strike anytime 
between May and November (the 
medical center was built to be 
typhoon-proof). All facilities nor- 
mally available at a large military 
base are handy — commissary, ex- 
change, post office, schools, reli- 
gious services, recreation and en- 
tertainment. Local English lan- 
guage media include military radio 
and TV stations, two newspapers, 
and two civilian -operated radio 
stations. 



Volume 67, June 1976 



Rehabilitation 



For a Pioneer: 
A Medal 



He had been an alcoholic, and he 
might have been one of life's per- 
manent losers. Instead, he fought 
back. More than that, he helped 
other alcoholics fight back, too. And 
one day last March he stood with his 
wife while the Navy Surgeon Gener- 
al pinned on his lapel the Distin- 
guished Civilian Service Medal. 
Richard Jewell, retired Navy com- 
mander and recovered alcoholic, 
was firmly in the winner's circle. 

One of the highest federal honors 
ever given to a worker in the field of 
alcoholism treatment, the award 
was presented to Jewell for his 
pioneering role in founding the 
Navywide alcoholism prevention 
and treatment program. 

Jewell began his volunteer work 
with alcoholic Navymen in 1965, 
eight years after retiring from the 
Navy. "I wanted to help people on 
the base who needed it," Jewell 
said in a recent interview in Wash- 
ington, D.C., "because in those 
days most military doctors didn't 
know how to treat alcoholics. It 
wasn't a subject taught in medical 
courses." 

After gaining his sobriety in the 
early 1%0's, Jewell worked full- 
time with alcoholics at Naval Station 
Long Beach, California. "I wanted 
to show the doctors that there was a 
way out for alcoholics," he said. In 
1969 he became a staff member of 
the Alcohol Rehabilitation Center, 
NRMC Long Beach. He retired from 
this position last year. 

One of Jewell's early supporters 
was CAPT Joseph J. Zuska (MC), 
who headed the Long Beach ARC 
until his retirement in 1974. Along 
with several other Navy physicians, 
he encouraged Jewell to start group 
meetings and therapy sessions for 
alcoholics. But the doctors had no 
facilities to offer other than their 
own offices after hours. "So we be- 




Richard Jewell receives award from Navy Surgeon General 



gan with only a few people in a cap- 
tain's conference room," Jewell 
recalled. 

At first people were shy, fright- 
ened and hesitant to label them- 
selves alcoholics. "We weren't en- 
tirely successful right away," 
Jewell said, "because none of us 
knew how to handle the situation. 
Gradually, by trial and error, we 
began to have some success in 
getting people off the bottle, and 
keeping them off." 

Later he was given an empty 
quonset hut that had a bare 
assembly hall and some office space 
with a phone. "And that," he said, 
"was the beginning of our alcohol- 
ism clinic." 

"Of course, everything wasn't 
roses right off," Jewell continued. 
"We had to fight battles from top to 
bottom to keep our clinic on base 
because some people were ashamed 
to have it there." 

Jewell stressed that in those days 
alcoholism in the military was con- 
sidered a disciplinary problem. 
Very few people understood that it 
was a treatable disease. 

In 1967, two years after its estab- 
lishment, the Long Beach "clinic" 
received official recognition and be- 
came the Navy's first alcohol reha- 
bilitation center. Several years 
later, another center was opened in 
Norfolk, Virginia, using treatment 
and rehabilitation methods devel- 
oped at Long Beach. Today, there 
are five major centers at naval bases 
around the country, 14 smaller units 
at naval hospitals, and more than 40 
locally designated facilities at com- 
mands worldwide. Any Navy man or 




Richard Jewell, with medal 
A way out for alcoholics 

woman who may have a drinking 
problem can walk in, or request to 
be sent to a center for treatment. 

Recovery rates appear encourag- 
ing. According to official studies, 
from 1965 to 1975 more than 12,000 
alcoholics have been given help; 
70% have been successfully re- 
stored to duty. 

To augment its program, the 
Navy has over 250 part-time alco- 
holism counselors. The Navy also 
offers training for full-time counsel- 
ors, and publishes films and litera- 
ture for Navy audiences. 

Of his role in breaking the ground 
for alcohol treatment in the Navy, 
Jewell said, "I had the problem my- 
self and beat it. I knew others could, 
too. I'd been in the Navy and so took 
my ideas to them. If I've helped, 
that's what I started out to do, and 
that's all I can ask for." 



U.S. Navy Medicine 



From Surgeon's Steward to Specialist: 

Hospital Corpsmen, Then and Now 



HMCS Frank J. Scanlon 



Holding sick call on a destroyer in 
the Atlantic . . . updating a Marine 
Corps unit's medical supplies . . . 
providing nursing care for new- 
borns . . . wherever you find Navy 
hospital corpsmen, you can count on 
top-flight health care. Low in num- 
bers but high on quality, corpsmen 
have come a long way since Con- 
gress established their rating in 
1898. To mark the Hospital Corps' 
78th birthday on 17 June, HMCS 
Frank J. Scanlon briefly charts its 
proud history: 

Since the original group of 25 
pharmacy technicians, thousands of 
men and women have worn the 
Hospital Corps' Geneva Cross and 
caduceus. 

From the first surgeon's steward 
to today's highly trained and talent- 
ed technicians, hospital corpsmen 
have been among the most versatile 
of Navy personnel. During even a 
short career, a corpsman's duty as- 
signments can range from a busy 
regional medical center to challeng- 
ing field duty with the Marines or 
sea duty with the fleet. 

Wherever Marines and sailors 
have served, corpsmen have been 
with them. In fact, if quarters for 
muster, inspection and instruction 
were called for all corpsmen past 
and present, those answering 
"aye" could give us a complete pic- 
ture of American naval history. 
John Wall, the Navy's first known 
loblolly boy, could describe the 
battle between the U.S. frigate 



HMCS Scanlon is on the staff of the Hos- 
pital Corps Division, Bureau of Medicine and 
Surgery (Code 34), Washington, D.C. 20372. 



Constellation and the French frigate 
L Insurgente on 9 February 1799. 
Alexander Wood, another loblolly 
boy, could chronicle life aboard the 
Essex. John Domyn could tell how 
Algerian pirates captured him with 
the crew of the Philadelphia at 
Tripoli. 

Through the American Revolu- 
tion, War of 1812, Civil War, Boxer 
Rebellion, World Wars I and II, and 
in Haiti, Korea and Vietnam, the 
men and women of the Hospital 
Corps set the highest performance 
standards. Although their titles 
changed — from loblolly boy to sur- 
geon's mate, bayman, apothecary, 
pharmacist's mate, and finally hos- 
pital corpsman — their contributions 
were invariably significant. There 
were no supermen. We had our 
share of fools and wise men, 
workers and shirkers, outlaws and 
law -keepers. But we had our share 
of heroes, too: 21 corpsmen have 
received the Medal of Honor. Their 
pictures now have an honored place 
on the walls of the Hospital Corps 
school buildings where they learned 
the basics of their rate. 

Today's corpsman can choose 
from some 46 medical specialties. 
But he — and now frequently she — is 
as versatile as his predecessors: 
operating room, physical and occu- 
pational therapy, and neuropsychi- 
atric technicians are all able to pro- 
vide basic patient care in addition to 
their specialized skills. Corpsmen 
have filled sandbags, built and 
manned battle dressing stations, 
manned general quarters stations, 
and heroically defended the sick 
and injured in their care. 



What would loblolly boy John 
Wall say if he were asked to relieve 
HMC Robert M. Harris of Seal 
Team No. 2? Could he, like CAPT 
Albert J. Schwab, rise from corps- 
man to chief of the Medical Service 
Corps, overcoming captivity in a 
Japanese prison camp? How many 
early corpsmen would have earned 
a medical degree after leaving the 
Navy, then return to serve their 
shipmates as did former hospital 
corpsmen RADMs Joseph T. 
Horgan, William J. Jacoby, Jr., 
Paul Kaufman, Walter M. Loner- 
gan, Edward J. Rupnik, and 
Charles L. Waite? Nurse Corps offi- 
cers who followed the same corps- 




April 1918: Navy hospital corpsmen 
in France behind the front lines. 



Volume 67, June 1976 



man-to-officer route include CDRs 
Joan Mclntyre, Donna Barbarick, 
Margaret Whitesell, and LCDR 
Bobby Huskey. 

It would take years of preparation 
to make loblolly boy Alexander 
Wood a suitable replacement for 
HM1 Robert Wida, Medical Depart- 
ment representative aboard the USS 
Francis Marion. John Domyn would 
have had to burn a lot of midnight 
oil to learn the job of HM3 Thomas 
E. Hardy, cardiopulmonary techni- 
cian at Naval Regional Medical 
Center Great Lakes. 



Enlisted Scene 




Corpsmen with lifelike dummy "Oscar" 



In fact, early hospital corpsmen 
would have to hustle just to keep up 
with today's talented breed — men 
and women like HM3 Julio M. 
Maldonado of Naval Undersea Med- 
ical Institute; HM1 Jane Kroeze, a 
transplantation technician at Naval 
Medical Research Institute; HM3 
Karl Farmer, recently transferred 
from the Nursing Service at Naval 
Regional Medical Center Charles- 
ton to the USS McDonnell; HM3 
Archie H. Jahnke of Naval Regional 
Medical Center San Diego; or HM3 
Daniel F. Gruendemann, attached 
to the 1st Battalion, 6th Marines, 
2nd Marine Division. 

They are strong, self-reliant, re- 
sourceful men and women, proud of 
their heritage and their jobs. Their 
accomplishments will make a fitting 
legacy for tomorrow's corpsmen. 



Planning to Reenlist? 

If you plan to reenlist or extend 
your current enlistment, check with 
your career counselor or personnel 
office to make sure you are eligible. 
You should also review BUPERS 
Instruction 1133.22D for revised re- 
enlistment criteria (part of the Re- 
enlistment Quality Control Pro- 
gram) and terms of reenlistment by 
length of service. BUPERS Instruc- 
tion 1133.25C placed hospital corps- 
men in career reenlistment objec- 
tives (CREO) Group "E," which 
means you must obtain BUPERS 
approval before you reenlist or 
extend your enlistment if you have 
less than 10 years' day-for-day 
active military service. Read these 
instructions now, so you can reenlist 
at the time and in the way you 
prefer. Otherwise, you may be dis- 
appointed if your plans must be 
changed at the last moment. 

Hoping to Advance? 

BUPERS Notice 1430 of 2 Febru- 
ary 1976 announced revised time-in- 
service and time-in-rate require- 
ments for advancement to pay 
grades E-7, E-8 and E-9 (including 
active and inactive Reservists): 

• Effective 1 November 1976: To 
advance to E-9 you must have 15 
years of service and have been an 
E-8 for 3 years. To advance to E-8, 
you must have completed 12 years 
of service. 

• Effective 1 January 1977: To 
advance to E-7 you must have 9 
years in service. The time-in-rate 
requirement is 3 years as an E-6. 

Despite these new requirements, 
E-8 and E-9 candidates who took the 
November 1975 exam, and E-7 can- 
didates who took the January 1976 
exam and were not promoted will 
still be allowed to compete for 
advancement in the November 1976 
E-8/9 and January 1977 E-7 exams 
if they are eligible and recom- 
mended by their commands. 



Advanced Training 
"C" Schools 

Competition for advanced train- 
ing "C" schools is keen. Quotas 
("school seats") are limited, while 
requests for this training are almost 
unlimited. Not all applicants who 
meet qualifications for "C" school 
assignment can be selected. To 
ensure that the selection of students 
is fair, BUMED has established a 
"C" school selection committee 
which meets quarterly. Factors 
which influence selection are: the 
applicant's qualifications, projected 
rotation date, previous advanced 
training in another specialty, aca- 
demic and on-the-job performance, 
and quotas in the school requested. 

Training and personnel officers 
should make sure that requests for 
"C" school training are submitted 
on NAVPERS 1306/7 to BUPERS, 
through the Enlisted Personnel 
Manpower and Accounting Center 
(EPMAC) and BUMED. The appli- 
cant must meet prerequisites out- 
lined in the Catalog of Navy Train- 
ing Courses, NAVEDTRACOM 
Form 1500/1. All items on Form 
1306/7 should be completed and 
verified by the applicant and his 
command. The application must 
include a command endorsement 
and appropriate enclosures (SF-88, 
SF-93, academic records and special 
examination reports). 

BUPERS sometimes receives re- 
quests to cancel "C" school train- 
ing after an applicant has been 
selected, usually because the selec- 
tee doesn't want to perform the 
obligated service. Often it is too late 
to select another student for the 
training slot; the school seat is left 
vacant and someone else, who 
wanted the training, may lose the 
chance to get it. We cannot say it 
too often: know the obligated ser- 
vice requirements before you apply 
for training. 

— HMCM Horace S. Anderson. Master Chief Petty Offi- 
cer of the Force. 



U.S. Navy Medicine 




NAVMED Newsmakers 



American Medical News 

CAPT Spangler: Winning 




\W 



HM1 Sapp: Dashing 



Keeping up with retired Navy medi- 
cal folks can leave you breathless, espe- 
cially if you're chasing Paul E. Span- 
gler, retired Navy surgeon and incur- 
able jogger. CAPT Spangler, age 77, 
has huffed and puffed his way to many 
world records for his age group since he 
began running competitively last year. 
When we last heard from him, the fleet- 
footed sprinter had won five national 
championships and set four world 
records at the National Amateur Athlet- 
ic Union's master meet in White Plains, 
N.Y, Says the indefatigable doctor, 
"I'm running more than ever and will 
never quit. It's never too late to start — I 
didn't get smart until I was 67." 

When ABC-TV Nightly News reporter 
Bob Furnard needed the last word on 
hypothermia, he headed straight for 
Navy medicine's cold weather medicine 
experts: retired RADM William Mills 
(MC) and CAPT Paul E. Tyler (MC) of 
Naval Medical Research and Develop- 
ment Command. The interview, video- 
taped at National Naval Medical Center, 
warmed up a Saturday night news story 
on the dangers of spring camping and 
hiking. 

For two hospital corspmen at Naval 
Hospital Cherry Point, "Emergency" is 
more than a television program: it's the 
story of their lives as members of the 
Cherry Point rescue squad. HM3 Ed 
Heath and HN Doug Conley bring 




Post 601: Exploring 

Volume 67, June 1976 



know-how and quick reflexes to their 
work. They take information from 
callers, dispatch the ambulance, make 
sure that the emergency room is stand- 
ing by, and check supplies in the medi- 
cal crash kit. Their biggest headache: 
people who don't pull over for the am- 
bulance. "People see the red light 
flashing, but they don't pull over be- 
cause the siren isn't going," says HM3 
Heath. "We usually don't sound the 
siren because it scares the patient. 
Many minutes could be saved if people 
would just pull off the road." 

Education fever is sweeping NRMC 
San Diego, and no one's making the 
slightest effort to slow it down. A typical 
achiever is HM1 Joseph Sapp, who 
dashes from his full-time job in the lab 
of the blood donor center to evening 
class in health care administration at 
the Naval School of Health Sciences. 
More than 100 Navy go-getters as- 
signed to the medical center are using 
their education benefits while on active 
duty. 

Also making Navy medicine head- 
lines this month were: HM1 Charles C. 
Eggleston, named Sailor of the Year 
aboard the USS John F. Kennedy for 
outstanding work as an X-ray techni- 
cian . . . BUMED's chief biomedical en- 
gineer, CDR John P. Swope (MSC), 
who's just become the Navy's first 
board-certified clinical engineer . . . HN 
Pat Schaeffer, named Miss Military 
Little Creek, Virginia, and runner-up 
DT3 Nancy Shemella, both from Naval 
Amphibious Base Little Creek . . . and 
DT3 Bruce Roemer, who boxed his way 
to the 1976 all-Navy middleweight 
championships. 

From today's medical explorers come 
tomorrow's health professionals — and if 
they're members of Medical Explorer 
Post 601 at NRMC Memphis, they may 
well choose careers in Navy medicine. 
Timothy Barrett recently received his 
Post's charter from explorer scout 
executive Bill Robinson, as advisers — 
LCDR Joe Beene (MSC), LTJG 
Georgene Gibbs (NC), and HMC Doyles 
Grimes — looked on. Not content at just 
turning teens on to Navy medicine, the 
medical center also sponsors a younger 
Boy Scout troop and a Cub Scout pack. 



Off Duty 



Mountain Medicine 



The Medical Department's con- 
cern for human well-being doesn't 
end with its military obligations, as 
a remote Taiwanese mountain vil- 
lage recently found out. 

LCDRs Jim Sebastian (MC) and 
Robert Post (DC), HM1 Wellman 
Wong, and DT2 Tom Deslauriers 
took annual leave in February to ac- 
company civilian nurses and mis- 
sionaries to Hau Cha Village. Their 
mission: to provide badly needed 
medical and dental care to the 
village's 120 families. Organized by 
China Free Methodist missionaries 
Harry and Ruth Winslow, the medi- 
cal/dental team also included regis- 
tered nurse Kathy Rees (a Navy 
wife), and interpreter John Thomp- 
son of the United States Information 
Service, Kaohsiung. 

The group hiked 5600 feet up the 
mountains of south central Taiwan 




Crude stove turns sterilizer 



to reach the isolated village. Native 
packers carried 85-lb supply packs 
up a 45-degree grade more easily 
than the visitors could manage the 
rough terrain with no gear at all. 

In Hau Cha, LCDR Sebastian, an 
obstetrician and gynecologist for- 
merly assigned to U.S. Naval Hos- 
pital Taipei, saw more than 200 pa- 
tients in Ob/Gyn, geriatric, well 
and sick baby, and general sick call 
clinics. HM1 Wong — an indepen- 
dent duty hospital corpsman sta- 
tioned in Tsoying — ran the make- 
shift pharmacy, sterilizing instru- 
ments over a crude wood-burning 
stove. 

LCDR Post examined 185 pa- 
tients, 60 of whom required dental 
extractions. (By day's end, 160 
teeth had come out.) Both he and 
DT2 Deslauriers lectured on pre- 
ventive dentistry; their instructions 
were translated by John Thompson 
into Mandarin Chinese, and then 
from Mandarin into the native lan- 
guage by a local teacher. The dental 
team also distributed 200 tooth- 
brushes to the villagers, many of 
whom had never seen or used one. 

In a village without electricity, 
the Americans relied on the sun — 
moving the dental clinic four times 
in one day to take advantage of 
every bit of sunlight. As the sun 
went down, the team turned to 
flashlights to continue their work. 

Of all the revelations in store, 




most surprising was the villagers' 
ability to withstand pain. In one 
case, LCDR Post administered local 
anesthesia to a third grader and 
removed 10 abscessed teeth in 20 
minutes while the child showed not 
a trace of discomfort. "They're 
made of something stronger than 
we are," he said of the stoic vil- 
lagers. 

The Americans stayed in the vil- 
lagers' homes and shared their 
meals — millet, roots, and fish. 
There developed the kind of com- 
passion and respect that has always 
been the hallmark of good medical 
practice. "Without the total cooper- 
ation of the villagers, without their 
discipline and tolerance for discom- 
fort, we could not have accom- 
plished what we did," Dr. Post said 
at the end of the visit. 

"The team's service to this 
village was given in a wonderful 
spirit of love," said Mrs. Winslow. 
"They will never be forgotten by 
the people they went to help." 

— LT Paul deWitt, USNR 

The Sweet 
Life 

First it was "The Birds." Then 
"Jaws." And at Naval Regional 
Medical Center San Diego, there's a 
cast of thousands ready for another 
movie thriller: "The Bees." 

But not to worry. According to 
the medical center's "Chief of Bee 
Swarms," CAPT John A. DeKrey 
(MC), there is no cause for alarm. 
The productive little insects are 
minding their own sweet business. 

A staff anesthesiologist, Dr. 
DeKrey says he first got interested 
in his unusual hobby when he found 
a swarm of bees in his backyard 
about five years ago and made a 
hive for them. Soon another swarm 
arrived, and he made more room. 

"I'm a farmer at heart," he says, 
"and raising bees is agriculture in 
its purest form." 

Navy dentistry in the mountains 



Home wasn't the only place Dr. 
DeKrey found his bees. At the med- 
ical center he found a swarm on the 
North Patio, another by the Credit 
Union office, another near Building 
26, and another in a manhole at the 
south end of Farenholt Avenue. 

Dr. DeKrey says many people are 
scared to death of bees. A woman 
visiting his apiary recently was typi- 
cally terrified when asked to don 
coveralls, boots, long gloves, hat, 
and net facemask. But she decided 
to be brave. After all, what harm 
were a few hundred bees simply 
buzzing around her face, arms, and 
legs? She was relieved when the 
bees did only what they're sup- 
posed to do: make honey. 

"There's no need for fright," Dr. 
DeKrey says. "Most people are 
stung by wasps, not bees. Bees only 
sting if you molest or anger them — 
if you step on one, for example. 
Really, bees are among the world's 
most beneficial insects." 

And among the most productive 
as well. Dr. DeKrey has harvested a 
ton of honey in one year from his 
apiary. After bottling the honey, he 
gave many jars to friends and pa- 
tients. And when the hospital spon- 
sored a fund-raising bazaar, the 
Department of Anesthesiology 
made out like bandits from its honey 
sales. 

The 32 boxes stacked in Dr. 
DeKrey' s apiary (four boxes per 
stack) don't look like beehives. They 
resemble drawers removed from a 
chest. In each of these "drawers" 
are 10 wood frames holding honey- 
combs. On each honeycomb, hun- 
dreds of bees make enough honey to 
feed the queen bee and the up to 
2,000 soon-to-be-hatched eggs she 
lays every day. 

In each hive, the queen bee is the 
center of attention, the worker bee 
the backbone. Worker bees produce 
honey from the nectar and pollen 
they collect. Queen bees, who never 
leave the hive, live up to eight 
years, Dr. DeKrey says, but worker 
bees usually live only six weeks, 
"The worker bee's life span is 
directly related to how much work it 



does. A bee can literally work itself 
to death." 

Drones are male bees whose only 
purpose is to mate with a queen. 
Fed by the worker bees, drones can- 
not sting, and their life span is 
short, sometimes just one season. 

Dr. DeKrey checks his apiary 
once or twice a week. "You can tell 
how things are going in the hive by 
whether the bees are flying or 
sitting around. Sometimes when a 
queen bee dies the bees act very 
peculiarly. They may sit around and 
mourn. Bees depend on their queen 
very strongly." 

Dr. DeKrey has had only one 
problem with vandalism in the 
apiary. "One morning I found 
someone had removed the lid from 
one of the hives," he reports. "He 
was probably trying to get some 
honey. I don't think he succeeded 
because about 20 feet away I saw 
the lid lying on the ground." 
Evidently, the would-be burglar 
was chased away by an indignant 
bee household. 

Taking care of the apiary is not 
difficult, says Dr. DeKrey, but 
harvesting the honey is more com- 



n* 






CAPT DeKrey tends a hive 



When full, this honeycomb will hold 
5 lbs of sweet stuff. 

plicated. "The bees need to be en- 
couraged to work, and need to have 
lots of elbow room. If the hive gets 
too full, the bees will loaf and not 
produce honey." Harvesting the 
honey gives the bees the room they 
need to make more. 

The harvesting process is a full 
weekend of work for Dr. DeKrey, 
depending on how many honey- 
combs or frames he has to handle. 
Bees build their honey-filled cells 
on the frame's waxy comb. When 
full, each frame holds about five 
pounds of honey. 

To remove the frames from the 
hives without angering the insects, 
Dr. DeKrey blows the bees off with 
a vacuum cleaner. Then he takes 
the frames to his home and, with a 
hot knife, cuts off the wax residue 
that caps the honey. He then spins 
the frame in an extractor, and 
strains the honey he gets through a 
cheesecloth. Then it's into bottles 
and onto the table. 

Bee fever is apparently conta- 
gious at San Diego. HM1 Howard 
A. Williams keeps two hives near 
his office. He has captured swarms 
at the medical center, in an air con- 
ditioner and near the Naval School 
of Health Sciences. 

San Diego's bees and beekeepers 
are looking forward to the day when 
Hollywood starts filming "The 
Sting— Part II." 

— Suzanne Choney, Dry Dock, NRMC San 
Diego, California 92134. Photos by HN Mark 
Steely. 



Volume 67, June 1976 




USS Belknap after the collision 

On Duty 



Collision at 
Sea 



When the guided missile cruiser 
USS Belknap collided with the 
aircraft carrier USS John F. Ken- 
nedy last November, medical crew- 
members saved lives through their 
quick action and superb skills. In 
this first-hand report, CDR James 
Wenger, senior medical officer 
aboard the Kennedy, tells how mass 
casualties were handled during the 
crisis: 

At 2205 on 22 November 1975, 
the collision alarm sounded on the 
USS John F. Kennedy, followed by 
a call to general quarters. Immedi- 
ately the ship's midsection was 
enveloped in dense, choking smoke 
that seemed to be coming from the 
port side. The smoke was so intense 
that all patients and most hospital 
corpsmen had to be evacuated from 
sick bay. The smoke also prevented 
the medical officer and medical 
administrative officer from reaching 
their stations in sick bay and 
damage control central. Since we 
didn't know the condition of the rest 
of the ship, we routed patients 
forward along the starboard pas- 
sage to the hangar deck. 

By patching bits of information 
together, we learned that the Ken- 
nedy and the USS Belknap had 
collided, causing fires in both ships. 



Material condition Zebra was set: 
watertight doors and hatches were 
closed to prevent fire from spread- 
ing from one compartment to the 
next. A skeleton crew, equipped 
with survival support devices, 
manned sick bay. Because of a 
serious fire on the flight deck, the 
CVW-1 flight surgeon and regularly 
assigned hospital corpsmen man- 
ning the battle dressing station 
there were joined by corpsmen from 
the main battle dressing station. 

Our three other physicians, our 
oral surgeon, and a team of corps- 
men and stretcher bearers met on 
the hangar deck to discuss the mass 
casualty plan with the medical 
administrative officer. Much of the 
ship was still filled with smoke and 
had no working lights. Firefighters 



were still working on the flight deck 
and in the port sponson. 

When further reports told us that 
the Belknap fire had caused second- 
ary explosions, we prepared for a 
large number of casualties from 
both ships. The forward battle 
dressing station and forward mess 
deck would be our main treatment 
areas until sick bay was restored. 
The #1 deck edge elevator area was 
designated as emergency forward 
battle dressing station and stocked 
with supplies and equipment from 
portable medical lockers and first- 
aid boxes. 

Casualties. Our plan for evacu- 
ating Belknap patients was to help 
them to the flight deck, down to the 
hangar deck via #1 or #2 starboard 
deck edge elevators, then down 




^ 



USS Kennedy: Casualties were amazingly low 



10 



U.S. Navy Medicine 



upper stage bomb elevators #1 or #3 
to the forward mess deck. Casual- 
ties would board the Kennedy from 
the USS Hart and USS Dale — two 
ships assisting in the rescue — to be 
evacuated to Branch Dispensary 
Sigonella and Naval Regional Medi- 
cal Center Naples. Flight deck crew- 
members who had seen the Belknap 
burn and explode predicted that 100 
to 200 severe casualties would 
arrive. 

The most seriously injured men 
began arriving from the Belknap by 
helicopter at 0230, after partial 
treatment by corpsmen and the 
CVW-1 flight surgeon. The men 
were badly burned; two had severe 
fractures of the upper arms. All 
were triaged, treated, and held at 
the forward battle dressing station 
until sick bay was smoke-free and 
ready to receive them at 0300. We 
drew blood specimens, inserted 
subclavian lines and indwelling 
catheters, stabilized fractures, and 
cleaned and debrided the wounds, 
redressing them with sulfamylon. 
Tetanus toxoid and prophylactic 
antibiotics were administered. By 
this time we had drawn 20 units of 
the four most common types of 
blood from our walking blood bank 
in the Marine detachment. 

About 0400, a Nurse Corps 
officer and chief hospital corpsman 
came by helicopter from the 
Sigonella branch dispensary to help 
care for Five critically injured pa- 
tients. They left with six litter 
patients — three from the Kennedy 
sick bay and three from the Dale — 
whose condition had stabilized. All 
seriously injured patients were ac- 
companied ashore by a hospital 
corpsman trained in search-and- 
rescue. 

At 1000, with 46 patients aero- 
medically evacuated, our exhausted 
crew caught a few minutes of rest as 
two physicians from NRMC Rota, 
Spain arrived with additional sup- 
plies. 

Aboard the Kennedy, our casual- 
ties were amazingly low: one as- 
phyxiation, three minor smoke in- 
halations, and two minor hand 
burns. Damage to the ship was 




injured men are brought by helicopter to the Kennedy 

i 




Damage aboard the Belknap 

greater: a large fireball had rolled 
across the Kennedy flight deck, port 
sponson fires blazed until 0500 and 
reflashed for 24 hours after the col- 
lision, and three of four main 
machinery rooms were knocked out 
by dense smoke. 

The USS Kennedy and its Medi- 
cal Department performed effec- 
tively in this crisis because we were 
prepared. Our emergency gear was 
in place, up to date, and ready to 
go. Our only problem: some 
sulfamylon manufactured in 1973 
had turned brown and grainy, 
despite its 36-month shelf life; this 
may have been caused by the high 
ambient temperature in the storage 
space. (NRMC Naples later re- 
ported the same problem with 
sulfamylon made in 1970.) 




Crewmember at memorial service 



Our mass casualty system worked 
because we planned it carefully and 
conducted many practice drills. We 
correctly planned to treat patients at 
the hangar deck triage station or the 
forward battle dressing station, 
keeping them out of sick bay until 
that area was completely restored. 



Volume 67, June 1976 



11 



We reserved sick bay for serious 
and critical cases, brought one at a 
time from the forward battle dress- 
ing station where they had been 
expertly managed by dental offi- 
cers, dental technicians and battle 
dressing station corpsmen. Men 
with slight injuries were treated 
elsewhere. This system allowed the 
ship's surgeon, the orthopedic sur- 
geon assigned on temporary addi- 
tional duty, and the senior dental 
officer to complete a full evaluation 
and start treatment before the next 
patient arrived. 

Success. Although damage con- 
trol central and sick bay were 
knocked out, the flexibility of our 
mass casualty plan ensured its 
success. As the lack of Kennedy 
casualties became clear, personnel 
assigned to the aft battle dressing 
station and the forward and aft 
auxiliary battle dressing stations 
were rotated to the flight deck, 
hangar deck or sick bay, or sent to 
get some sleep. The part of the crew 
that rested was ready the next 
morning to man battle dressing 
stations and resupply portable med- 
ical lockers and first-aid boxes. 

We learned some important les- 
sons from this experience: 

• Information about emergencies 
must be sent through reliable 
channels so the shore facility can 
accurately assess the situation. In 
our case, lack of timely information 
about the number of casualties 
hindered precise planning: the re- 
sponse was too great for our need. 
NRMC Naples, informed two hours 
after the collision that there had 
been a major accident at sea and 
told to prepare for large numbers of 
casualties, devised a plan to supple- 
ment Sigonella branch dispensary 
personnel with physicians and 
corpsmen from NRMC Rota. The 
2nd Medical Evacuation Group at 
Rhein-Main, Germany was also 
alerted to stand by for evacuation 
from Naples. Much of this prepara- 
tion, it turned out, was unneces- 
sary. 

• Keep medical personnel aboard 
ship unless there is a good reason to 
dispatch them. Our medical officer 



did not know that the CVW-1 flight 
surgeon had been directed to leave 
the flight deck battle dressing 
station and report to the Hart . Some 
of our medical decisions were there- 
fore based on the erroneous as- 
sumption that a physician was still 
on the flight deck. 

• Moving many patients in rigid 
litters up and down shipboard 
ladders is virtually impossible. Al- 
ternative methods should be worked 
out. 

• The Coast Guard flotation 
stretcher should be standard equip- 
ment. The standard shipboard high- 
line flotation stretcher is awkward 
for transferring large numbers of 
patients by helicopter, and is use- 
less when its shackles are lost. 




The Belknap is towed into Naples 

• The easiest way to handle pa- 
tients who require flotation gear is 
to put a Stokes litter inside the 
Coast Guard flotation litter and then 
remove only the patient and inner 
stretcher. This makes it much easier 
to move patients with burns or 
spinal cord injuries. 

• Have enough stretchers, espe- 
cially Stokes litters, before deploy- 
ment. Many of the Kennedy's 
litters are painted white and bright 
orange to make them easily visible; 
their location is stenciled on the 
wood so they can be restowed 
quickly. Since handling lines and 
straps can be easily pilfered, an 
extra supply of restraining straps 
should be available. Also, the 
handling lines on Stokes litters are 



cumbersome when moving patients 
onto helicopters and down crowded 
passageways; especially aboard air- 
craft carriers, Stokes litters should 
not be required to have handling 
lines unless the litters are used to 
carry patients up and down ladders. 

• Don't count on storeroom sup- 
plies. Dense smoke made our two 
main storerooms inaccessible for 
several hours. Prior dispersal of 
intravenous solutions, dressings, 
and resuscitative equipment was 
our only preparation for the antici- 
pated deluge of patients. 

• A flexible mass casualty plan is 
essential. One can never predict the 
kind of crisis that tests a ship's 
medical capability to the limit. Have 
a plan, and practice it often. For 
flexibility, someone in damage con- 
trol central should be familiar with 
medical care logistics. Our medical 
administrative officer, who is as- 
signed to the control center, re- 
turned there when it was cleared of 
smoke and secured good patient 
movement routes around the fire- 
fighting. 

• Crewmembers assigned to sick 
bay during mass casualty situations 
should stay where patients are 
initially received, in our case at the 
first major battle dressing station 
and then in the main battle dressing 
station. They are then better able to 
record patient flow. We did not 
have such a recorder, and it was 
only through elimination that we 
could later identify three patients 
moved from shipboard helicopters 
directly to the first shore-bound 
helicopter. 

• A designated medical emergency 
phone circuit or speaker system is 
vital to organize medical resources. 
The circuit should serve the sick 
bay, flight deck, forward and aft 
battle dressing stations and damage 
control central. Our standard ship's 
telephone system and damage con- 
trol circuits were almost worth- 
less. 

• Survival support devices were 
useful when living and working 
areas were evacuated. Each man 
should have at least one such 
device, and know how to use it. □ 



12 



U.S. Navy Medicine 



Notes & Announcements 



PACIFIC AREA MEDICAL/DENTAL LIAISON OFFICE DIRECTORY 



BUMED Notice 6000 of 12 March 1975 requires all naval 
hospitals and regional medical and dental centers to establish 
a fleet liaison office to support personnel assigned to 



operational billets. A directory for the Atlantic Fleet appeared 
in U.S. Navy Medicine in April 1976. Below is an updated 
directory of offices in the Pacific Fleet. 



NRMC SAN DIEGO, CALIF. 
Medical Liaison Office 

CAPT M.J. Valaske, MC, USN 
LT M.J. Benson, MSC, USN 
HMCM M. Luchter, USN 



Commercial 

Telephone 

(714) 233-2415 

(714) 233-2641 

1714) 233-2421/22 



Auto von 
727-3850 
727-3850 
727-3850 



Dental Liaison Office 

CAPT E.F. Sobieski, DC, USN 
LT G.R. Harrington, MSC, USN 
DT1 B.D. Goains, USN 



(714) 437-2955 
(714) 235-1177 
(714) 235-2171 



958-9955 
958-1534/1 176 
958-2171 



NRMC CAMP PENDLETON, CALIF. 
Medical Liaison Office 

CDR A.N. Urbane, MC, USN 
LT E.C. Wigle, MSC, USN 
HMCM D.L. Dittenhauser, USN 



[714) 725-1458 
(714) 725-1343 
1714) 725-1340 



993-1458 
993-1343 
993-1340 



Dental Liaison Office 

CAPT C.G. Strange, Jr., DC, USN 



(714) 725-1200 



993-1 200 



NRMC LONG BEACH, CALIF. 
Medical Liaison Office 

CAPT F.C. Leisse, MC, USN 
LT R.L. Ruoff, MSC, USN 
HMCS G. O'Keefe, USN 



(213) 420-5447 
(213) 420-5404 
1213) 420-5389 



873-9447 
873-9404 
873-9389 



Dental Liaison Office 
LT K. Vance, DC, USN 
LT A.E. Kennedy, MSC, USN 
DTCS A.T. Evangelista, USN 



(213) 547-7436 
(213) 547-7436 
(213) 547-7436 



360-7436 
360-7436 
360-7436 



NH PORT HUENEME, CALIF. 
Medical Liaison Office 

CDR W.L. Lovett, MC, USN 
LCDR R.P. Bauley, MSC, USN 
HMCS L.A. Wink, USN 



I805) 982-4501 
(805) 982-4501 
(805) 982-4501 



360-4501 
360-4501 
360-4501 



Dental Liaison Office 

Same as Dental Liaison Office, 
NRMC Long Beach, Calif. 



NRMC OAKLAND, CALIF. 
Medical Liaison Office 

CAPT D.Q. Wilson, MC, USN 
LT J,F. Renish, MSC, USN 
HMCM R, Brown, USN 



(415) 639-2115 
(415) 639-2041 
(415) 639-2357 



836-6141 

855-2041/2043 
855-2358/2357 



Dental Liaison Office 

CAPT J.W.R. Anderson, DC, USN 
LT S.R. Hixson, MSC, USN 
DTCM J.N. Stutz, USN 



(415) 765-5684 
(415) 765-6892 
(415) 765-6892 



869-5554 
869-6892 
869-6892 



NRMC BREMERTON, WASH. 
Medical Liaison Office 

CDR R.A, Nelson, MC, USN 
CDR C.W. Bollinger, MC, USN 
LTJG V.M. Wilson, MSC, USN 
HMC M. Barker, USN 



(206) 478-4204 
(206) 478-4258 
1 206) 478-4415 
I206) 478-4367 



439-4204 
439-4258 
439-441 5 
439-4367 



Dental Liaison Office 

CAPT J.E. Miller, DC, USN 
DTCM D.E. Denton, USN 



(206) 478-2213 
(206) 478-2213 



439-2213 

439-2213 



Volume 67, June 1976 



13 



NH WHIDBEY ISLAND, WASH. 
Medical Liaison Office 
CDR J.P. Senn, MC, USN 
LT J.L. Raymond, MSC, USN 
HMCM W.B. Sprague, USN 

NAVREGMED CLINIC PEARL HARBOR, 
OAHU, HAWAII 

Medical Liaison Office 
Pearl Harbor 

CAPT L. Eske, MC, USN 

LT R.F. Figura, MSC, USN 

HMCS D.A. Martinez, USN 
Barbers Point 

CAPT N. Sanborn, MC, USN 

LT B.T. Sparks, MSC, USN 

HMCM N, Perea, USN 
Kaneohe 

CAPT L.R. Fout, MC, USN 

LT R.E. McKee, MSC, USN 

HMCS T.M. Daniels, USN 

Dental Liaison Office 

LT J.E. Moriey, DC, USN 
LT D.J. Todd, MSC, USN 
DT2 D. Ellenburg, USN 

NRMC GUAM 

Medical Liaison Office 

CAPT R.B. Wright, MC, USN 
LTJG J.E. Soliday, MSC, USN 
HMCM R.R. Huemme, USN 

Dental Liaison Office 
CDR M. Ervin, DC, USN 
LCDR L.R. Massen, MSC, USN 
DT2 J.H, Thomas, USN 

NRMC SU.BIC BAY, R,P. 
Medical Liaison Office 

CDR J.B. Lench, MC, USN 
LTJG T.A. Kulcsar, MSC, USN 
HMC A. A. Arreola, USN 

Dental Liaison Office 

CAPT N.H. Tracy, Jr., DC, USN 
DT1 A.S. Cruz, USN 

NRMC YOKOSUKA, JAPAN 

Medical Liaison Office 

CAPT R.C. Myers, MC, USN 
LCDR T.E. Thomas, MSC, USN 
HMCM J.R. Allmond, USN 

Dental Liaison Office 

CAPT W.R. Martin, DC, USN 
DTI D.M. Bell, USN 

U.S. NAVAL HOSPITAL TAIPEI, TAIWAN 

Medical Liaison Office 

LCDR J.W. Atdis, MC, USN 
LT L.S. Watts, MSC, USN 
HMCM W.E. Cox, USN 

Dental Liaison Office 

CAPT H.S. Samuels, DC, USN 
DTCS P.B. Worland, USN 



Commercial 

Telephone 

(206) 257-2068 

(206) 257-2640 

(206) 257-2028 



(808) 471-1256 
(BOS) 471-1256 
(808) 471-1256 

(808) 684-2205 
(808) 684-2205 
(808) 684-2205 

(808) 257-3365 
(808) 257-3365 
(808) 257-3365 

(808) 471-9636 
(808) 471-9636 
(808) 471-9636 



344-9329 
344-9335 
339-4224 

339-5266 
339-5146 
339-3175 



885-9213 
885-9213 
885-9213 

884-3245 
884-3245 



234-7134 
234-7134 
234-7639 

234-7140 
234-7140 



871-5711 
871-5711 
871-5711 



871-5717 
B71-5717 



Autovon 
820-2068 
820-2640 
820-2028 



430-0111 
430-0111 
430-0111 

430-0111 
430-0111 
430-01 1 1 

430-01 1 1 
430-01 1 1 
430-0111 

430-0111 
430-0111 
430-0111 



388-1110 
388-1110 
388-1110 

339-8147 
339-8147 
339-8147 



844-1101 
844-1101 

844-1101 



844 
844 



11011 
1101) 



Ask operator 
for 5-9213 



Ask operator 
for 4-3245 



234-1110 1x7134) 
234-1110 (x7134) 
234-1110 (x7639) 

234-1110 (x7140) 
234-1110 (x7140) 



723-5228 
723-5260 
723-5279 

723-5238 
723-5238 



14 



U.S. Navy Medicine 



TEN-DAY OPTION ELIMINATED 

Officers and enlisted personnel will no longer have 
ten days to retire or transfer to the Fleet Reserve 
rather than accept permanent change of station 
orders. The Bureau of Naval Personnel (BUPERS) 
cancelled the ten-day option after manpower studies 
showed that it contributed to an imbalance in 
sea/shore rotation and staffing. BUPERS Note 1800 
of 12 March 1976 implements the change. 



DENTAL OFFICER TRAINING REQUESTS 

Dental officers must apply by 1 August 1976 for 
full-time advanced training starting in the summer of 
1977. (BUMED's Dental Officer Training Committee 
meets in early September.) Officers should apply to 
the Naval Health Sciences Education and Training 
Command, Code 5, following new procedures de- 
scribed in BUMED Notice 1500 of 12 June 1975. The 
Manual of the Medical Department (Chapter 6, 
Section XVI, Articles 6-122—6-132) is being revised 
to reflect these new procedures. 

Dental officers should also adhere to the above 
BUMED notice when applying for part-time inser- 
vice and outservice training, professional board 
review courses, consultant and lecture programs, 
short courses, seminars and workshops. 

The Navy Dental Corps needs officers with public 
health training; one-year public health residencies at 
civilian institutions are available. 

Since there are currently enough dental officers 
trained at the postdoctoral fellowship level, applica- 
tions for such training are not encouraged. 



OCCUPATIONAL HEALTH, 
ANESTHESIOLOGY MEETINGS SET 

The 19th Navy Occupational Health Workshop will 
meet in Charleston, South Carolina, from 27 Septem- 
ber to 1 October 1976. For details contact Ms. Bar- 
bara Halterman, Navy Environmental Health Cen- 
ter, 3333 Vine Street, Cincinnati, Ohio 45220. Or 
phone (Area code 513) 684-3863, Autovon 989-3863. 

The Navy's Seventh Annual Anesthesiology 
Symposium, a refresher course on "Problems in 
Anesthesia," will meet 9-11 September 1976 at 
Naval Regional Medical Center Portsmouth, Virgin- 
ia. For information, contact CAPT R.H. Norton 
(MC), Box 455, Naval Regional Medical Center 
Portsmouth, Virginia 23708. 



TRAUMA SYMPOSIUM HELD 
AT NRMC LONG BEACH 

Active-duty and Reserve naval medical units in 
California worked together on a one-day Trauma 
Symposium held 13 March 1976 at Naval Regional 
Medical Center Long Beach, California. The sympo- 
sium was planned by CAPT E.P. Rucci (MC), CO of 
NRMC Long Beach, and CDR Attila Felsoory (MC, 
USNR-R), CO of Naval Regional Medical Center 
5819, Encino, California. 

Some 228 active-duty, Reserve and civilian physi- 
cians, dental officers, nurses and paramedics shared 
their expertise in management of orthopedic prob- 
lems; high velocity missile wounds; chest, tracheal, 
bronchial, head, spine and urogenital injuries; blunt 
abdominal trauma; forensic medicine and ballistics; 
triage and mass casualty handling. Attendees 
received eight hours of continuing education credit 
from the International College of Surgeons. 



HQ MARINE CORPS MEDICAL CONFERENCE 

How to provide better health care to the Fleet 
Marine Force— that was the subject of a medical con- 
ference held 2-6 February 1976 at Headquarters 
Marine Corps in Washington, D.C. Senior medical 
officers of major Marine Corps commands, Head- 
quarters Marine Corps, and the Marine Corps De- 
velopment and Education Command attended the 
meeting, along with staff members from BUMED 
and the Naval Medical Materiel Support Command. 
Conferees discussed the organization of Marine 
Amphibious Force medical elements under the com- 
bat service support concept. Also covered were 
medical organization tables, Navy manpower allow- 
ances, and redistribution of Navy personnel within 
the combat service support organization. 

Similar meetings are planned for the future to pro- 
vide an exchange of ideas among experts in Fleet 
Marine Force operational medicine.— BUMED Code 
54. 

SIXTH ASIAN-PACIFIC CARDIOLOGY 
CONGRESS SET FOR 3-8 OCTOBER 1976 

The Sixth Asian-Pacific Congress of Cardiology 
will be held in Honolulu, Hawaii, 3-8 October 1976. 
For program and registration information, contact 
CAPT D.R. Canete (MC, USNR), Hawaii Heart As- 
sociation, 245 N. Kukui Street, Honolulu, Hawaii 
96817. 



Volume 67, June 1976 



15 



Soundings 

Division Officers/Leading Petty Officers: 

New Help for Hospitals 

HMCM Thomas G. Gardner, USN 



During recent years, the status, authority, responsi- 
bility, and accountability of the petty officer has been 
seriously eroded. The cause of this change is not the 
major issue. The real issue, and the task at hand, is to 
restore the petty officer's image and status, to strength- 
en the Navy by making the petty officer more useful. 

Many problems arise when petty officers do not 
participate fully in accomplishing the mission. Three 
trouble areas which have the greatest effect on morale 
and productivity are: 

• Communications. A communications gap may exist 
when people are unsure of command policies, and do 
not know what to expect from the command or what the 
command expects from them, 

• Petty officer development. The Navy stresses con- 
tinuous learning in professional and management 
areas. If petty officer participation and command sup- 
port for petty officer growth are lacking, both areas 
suffer. The more noticeable loss will be in leadership 
and management. 

• Administration. Good management requires flexible 
leadership at each level of supervision. If supervisors 
lack this quality the overall capability of the unit is 
diminished. 

Some of these leadership/management deficiencies 
were noted at Naval Regional Medical Center, Great 
Lakes, Illinois. To correct them, we instituted a Division 
Officer/Leading Petty Officer Program (DO/LPO) in 
February 1975. The concept is not new, its feasibility 
and effectiveness having been amply demonstrated in 
shipboard organization. But because the organizational 
structure of a naval regional medical center is so differ- 
ent from a naval vessel's, we had to find our own 
answers to a number of unique problems. 

By organizational structure, the medical center's 
senior medical officers, ward medical officers, and 
chiefs of services are responsible for the administration 

HMCM Gardner is master chief petty officer of the command at 
Naval Regional Medical Center, Great Lakes, Illinois 60088. 



16 



(including personnel management) of their respective 
clinical areas. It would logically follow that these indi- 
viduals would be the ideal choice for the job of division 
officer. However, in medical facilities such assignments 
are frequently impractical. Many officers spend long 
hours in surgery, clinics, and meetings, or have other 
duties which keep them from serving as division 
officers. Some enlisted personnel, particularly those on 
evening or night duty, rarely see their division officers; 
other staff members work in areas remote from their 
supervisor's jurisdiction. Nevertheless, the division 
officer concept, as it is designed to function in the 
Navy, cannot be summarily discarded because of these 
difficulties. 

IMPLEMENTING THE CONCEPT 

Implementing the DO/LPO concept at NRMC Great 
Lakes presented many problems. Chief among them 
was identification of division officers and leading petty 
officers with enough experience and leadership to train 
and guide junior enlisted personnel. Our solution: use 
Medical Service Corps officers with prior enlisted 
service, and augment this group with selected Nurse 
Corps officers and Medical Service Corps officers with- 
out enlisted service. 

We selected leading petty officers (LPO's) based on 
their seniority, maturity, experience, and leadership 
potential. Most of the responsibility for implementing 
the program rested with the LPO, who had better 
rapport with junior enlisted personnel. Because few 
senior petty officers were assigned to wards and clinics, 
we had to draw LPO's from other work areas. Many 
LPO's therefore became responsible for the welfare and 
morale of enlisted personnel assigned to work areas 
where the LPO has no direct authority over the daily 
performance of his charges. 

We named one division officer and one LPO for each 
20 to 25 enlisted personnel, E-6 and below. Division 
assignment was by ward, clinic, branch or administra- 

U.S. Navy Medicine 



tive function (e.g., Supply, Personnel, Security). One 
DO/LPO team might be responsible for the enlisted 
personnel on one or more wards, as well as an 
administrative office. 

DUTIES AND RESPONSIBILITIES 

The directive implementing the program outlined the 
following minimum duties and responsibilities of the 
DO/LPO team: 

Conduct division meetings, at least monthly, to discuss policy and 
actions impacting on personnel, base services available, various 
training programs available, etc. 

Promote and encourage qualified personnel to consider the 
advantages of a Navy career. 

Ensure that individual performance is recognized and rewarded. 

Personally interview individuals placed in disciplinary status. Take 
corrective action within the petty officer's limits of authority. Attend 
mast proceedings. 

Review periodic evaluations, and discuss with the individual the 
significance of these evaluations. 

Encourage and assist personnel to prepare for advancement in rate 
and to obtain off-duty education. 

Be available for discussion of personal problems. Provide informa- 
tion and guidance to help individuals solve personal problems and 
progress professionally and personally. 

Ensure that personnel are fully aware of and adhere to regulations. 

Ask assigned personnel to suggest ways to improve work methods, 
and to conserve time, labor, and funds. 

Instill a sense of personal pride and responsibility in junior person- 
nel by explaining the vital role each individual plays in accomplishing 
the command's mission. 

Set a good personal example for junior Navy members. 

Several problems arose when the program went into 
effect. We needed to improve our method of com- 



municating command policy. A few of the younger, less 
experienced members of the DO/LPO teams did not 
participate fully; on rare occasions, we had to replace a 
team member whose efforts did not meet our 
standards. Also, because of working hours or the 
physical location of some departments, it was 
frequently difficult for the DO/LPO team to arrange 
group meetings, or to provide the necessary monitor- 
ing. 
We are trying to solve these problems by: 

• Giving each DO/LPO a copy of policy statements 
which directly affect members of the command (e.g., 
liberty, leave, advance pay, assignment, grooming 
standards). 

• Providing leadership/management training for DO/ 
LPO personnel. We send people to local programs 
sponsored by Chief of Naval Personnel, and also pro- 
vide short-term training sessions conducted by mem- 
bers of the medical center staff. 

• Monitoring the work of the DO/LPO teams through 
team meetings, chaired by the medical center or 
director of administrative services. 

• Ensuring that DO's and LPO's have time to conduct 
meetings, and counsel and support division members. 

• Inviting each DO/LPO to attend a formal nonjudicial 
punishment session and ensuing discussions to become 
familiar with the command's philosophy regarding 
discipline. 

• Requiring monthly reports to the master chief petty 
officer of the command of topics discussed, complaints, 
and beneficial suggestions obtained through division 
meetings. 

(Continued) 



BUMED RESPONSE 



The excellent program HMCM Gardner describes is 
already in operation (perhaps with some modifications) 
at other naval regional medical centers. 

If it is true that in some areas the status, authority, 
responsibility and accountability of the Navy petty offi- 
cer has been seriously eroded, we should be concerned 
about the cause of this decay. The cause must be 
identified and eliminated before the problem can be 
solved. 

I agree that the petty officer's image is lower today 
than in years past, but many petty officers have not 
accepted their responsibilities nor exercised their au- 
thority as they should. The petty officer's status may 
have been given away rather than taken away or 
eroded. 

To avoid a "communications gap" each member 
should be welcomed aboard upon reporting to a com- 
mand. Their orientation should include introductions to 
key personnel, and an explanation of command policies 



and functions. Questions should be answered fully to 
preclude any misunderstandings. If the command has a 
particular philosophy regarding discipline, it should be 
explained at this "Welcome Aboard" meeting. 

While all individual performance should be recog- 
nized, not all will merit awards; some will merit repri- 
mand, which must be administered fairly and swiftly. 
(Those who deserve rewards should also be recognized 
promptly and publicly.) 

Finally, the master chief petty officer of the 
command, if allowed to function as intended, can help 
avoid a communications gap. The door to the MCPOC's 
office should be open at all times to every enlisted 
person within the command; the door to the command- 
ing officer should be open to the MCPOC. This practice 
will ensure a smooth flow of communication up and 
down the chain of command. 

—HMCM H.S. Anderson, USN, Master Chief Petty Officer of the 
Force, BUMED Code 006. 



Volume 67, June 1976 



17 



Morale is the most important indicator of the pro- 
gram's effectiveness. The morale of the organization 
directly influences other indicators, such as program 
support and discipline. As the understanding of policies 
increased and trust grew between the DO/LPO team 
and division members, morale improved; and as some 
of the members' beneficial suggestions were instituted, 
the value of the program as a way to gain recognition 
and satisfaction became more obvious. 

With DO/LPO personnel assuming more responsibil- 
ity for counseling and handling minor infractions, there 
was a noticeable drop in cases at mast. The number of 
people seen for nonjudicial punishment decreased from 
about 7 per week in early 1975 to 2 to 4 at year's end. 

The close rapport the DO/LPO team develops with 
staff members helps them identify problems in the 
Navy's Human Goals Program, including race rela- 
tions. It provides a similar opportunity for early identifi- 
cation of individual problems in professional and 
military development. 

NEW WATCH ASSIGNMENTS 

Among the operational problems brought up for 
command consideration was the issue of equitable 
watch. When a work study showed considerable 
inequity in the enlisted watch schedules, NRMC Great 
Lakes began to develop a new watch assignment 
system. Watch standers will be organized into eight 
divisions, each headed by a Medical Service Corps 
lieutenant commander as division senior watch officer. 
Since some functional departments have fewer than 
eight watch standers, effective cross-training of person- 
nel in the divisions is necessary, and there are sure to 
be exceptions. Each division will be assigned to train as 
a unit and will rotate watchers. We hope this new 
system will further promote a sense of esprit de corps 
among the divisions and staff, with cross-training as a 
side benefit. 

The drawbacks of the program are minimal consider- 
ing its value as a management tool. Some say that the 
time DO/LPO personnel spend counseling members in 
their charge should be devoted to routine duties at the 
medical center. But we believe the results of the 
program clearly justify this investment of time. 

The effectiveness of the program was tested recently 
at Great Lakes when austere funding required drastic 
command actions. Many programs normally taken for 
granted were reduced or dropped, and staff members 
were required to perform some tasks usually assigned 
to civilian public works personnel. The positive attitude 
and strong support by all hands was commendable. 

The early results of the DO/LPO program cannot be 
considered conclusive, but our experience so far sug- 
gests that this basic shipboard concept, when modified 
to fit the needs of a naval regional medical center, is a 
practical adjunctive management system. 



13 



Policy 



Instructions and 
Directives 



Navy Health Records 

On 1 July 1976, a major change takes place in the 
management and disposition of the health and dental 
records of Navy personnel separated from active 
duty on or after that date. These records will be 
closed and immediately delivered to the command 
maintaining the individual's service record. The 
health and dental record will thereafter always 
remain with the service record. 

This change does not pertain to the records of 
Marine Corps personnel who separate from active 
service. Their closed-out health and dental records 
will continue to be forwarded to BUMED. 

This change is Phase in of BUMED 's implementa- 
tion of the Master Medical Record concept, under 
which naval service personnel have only one health 
and dental record. In Phase I, the medical and dental 
records maintained at BUMED on active-duty Navy 
and Marine Corps personnel were returned to the 
individual's command for incorporation into his 
health and dental record. During Phase II, all 
medical and dental records held by BUMED on in- 
active duty Navy Reservists will be sent to the Naval 
Reserve Personnel Center, New Orleans. Records of 
drilling Navy Reservists will be sent to their com- 
mands. Phase U does not pertain to records of 
Marine Corps personnel. 

See forthcoming Change 88 to the Manual of the 
Medical Department for details. 

New physical standards for aviation personnel 

Flight surgeons should be aware of revised 
physical standards for flight personnel contained in 
Change 87 to the Manual of the Medical Depart- 
ment: 

• Because of the shortage of flight surgeons in 
designated billets, clinicians with previous flight 
surgeon designation will be allowed to perform avia- 
tion physical examinations. Such examinations are 
normally done by a flight surgeon or aviation medical 
officer on active duty in a flight surgeon billet or in 
an authorized aviation activity. However, when an 
operational flight surgeon is not available, a non- 

U.S. Navy Medicine 



operationally assigned flight surgeon or aerospace 
medical examiner, or a certified aviation medical 
officer may substitute. 

• A positive test for sickle cell trait or disease is a 
disqualifying defect for duty involving frequent 
flights. All Class 1 and Class 2 officers and officer 
candidates will be tested for sickle cell trait before 
starting flight training. Enlisted personnel with no 
prior sickle cell trait test on their health record will 
be tested before entering flight status. Civilians of 
ethnic origin known to have a high abnormal hemo- 
globin rate will be tested for sickle cell trait when 
they apply for programs that involve flying; if tests 
are positive for sickle cell trait, these individuals are 
ineligible for flight status. 

• Aircontrolmen are no longer under the aviation 
weight standard. They must now meet general ser- 
vice weight standards. 

• Hearing standards for all applicants, officer and 
civilian, for the Naval Flight Officer Program have 
been changed to coincide with hearing standards for 
commissioning. 

These changes apply to vision standards for Class 
I, Service Group 1 flight personnel: 

• Accommodation may be substituted as a test for 
near vision. Successful accomplishment of either the 
accommodation test or the near vision test satisfies 
normal near vision requirements. 

• The near point of convergence is changed from 70 
mm to 100 mm. Thus, a point of convergence greater 
than 100 mm is disqualifying. 

These changes in vision standards apply to candi- 
dates for flight training: 

• Prism divergence testing is deleted. 

• The limit on hyperphorias is changed from 1.0 to 
1.5 prism diopters. 

• Applicants who have altered their uncorrected 
distant vision with contact lenses should be 
identified. All applicants must sign a statement 
saying that they have never used contact lenses and 
that their uncorrected vision has never been less 
than 20/20. If the applicant cannot sign this state- 
ment, the examiner must make a full explanation, 
including an ophthalmology consultation. 

These changes in vision standards apply to Class 2 
personnel: 

• Navy naval flight officer (NFO) candidates should 
have distant visual acuity correctable to 20/20 in 
each eye. If uncorrected distant visual acuity is less 
than 20/40, glasses will be worn during flight duty. 
Marine Corps NFO candidates should have uncor- 
rected distant visual acuity in each eye not over 
20/200, correctable to 20/20 in each eye; they should 



wear corrective lenses while on flight duty if uncor- 
rected visual acuity is less than 20/40. All NFO 
applicants must meet certain refractive standards set 
forth in the Manual of the Medical Department 
[15-13(4)(a)(2)(Table 3}]. 

• When uncorrected distant visual acuity is less than 
20/40, vision must be corrected to 20/20 while on 
flight duty. The person must carry an extra pair of 
glasses while flying if uncorrected distant visual 
acuity is less than 20/100. 

• For crewmembers and enlisted parachute jumpers 
as well as naval flight officers, distant visual acuity 
must be correctable to 20/20 in each eye. If uncor- 
rected distant visual acuity is less than 20/40, correc- 
tion to 20/20 must be worn while on flight or 
parachute jumper duty. 

• Eye standards for student naval flight surgeons to 
solo have been changed from Service Group I stan- 
dards to Service Group II standards. 

Handling baggage in aeromedical evacuation 

New procedures for handling patients' baggage 
throughout the Military Airlift Command aeromedi- 
cal evacuation system are set forth in the enclosure 
to BUMED Instruction 4650. 7C of 6 April 1976. 

Physical Examinations for Divers 

Officers assigned to diving duty will undergo med- 
ical examinations within 30 days of their 24th, 27th, 
30th, 33rd and 36th birthday, and annually after 
that. There are two exceptions: saturation and exper- 
imental divers will be examined within one month of 
their birth date, regardless of age. Change 87 to the 
Manual of the Medical Department deletes a conflict 
with these requirements. 

Enlisted divers will continue to be examined with- 
in 3 months of their 18th, 21st, 24th, 27th, 30th, 
32nd, 34th, 36th, 38th, and 40th birthday, and 
annually thereafter. 

Care of grease gun /paint sprayer injuries 

People who use grease guns or paint sprayers risk 
injecting grease, paint, or other debris into the skin, 
particularly into their fingers and hands. Air- 
powered grease guns and paint sprayers operate at 
pressures up to 7,000 lbs. per square inch and can 
inject material at rifle speeds. Injected material can 
be driven great distances through the tissues. 

Although the injury appears deceptively minor at 
first— the entry wound is usually less than 2 
mm— extensive internal tissue damage causes great 
pain. Since circulation is impaired, damage in- 
creases with time, and the injury may produce life- 



Volume 67, June 1976 



19 



endangering infection. Frequently, the body part 
must be amputated. 

Surgical experience shows that early decompres- 
sion and debridement is the best treatment. Medical 
personnel should: 

• Consider any injury serious in which a high-pres- 
sure air or hydraulic system injects foreign matter 
into the tissues. 

• Be alert for associated injury. The wounded 
person may fall from a ladder or working platform, 
injuring other body parts. Pain from the injection 
injury may divert attention from other injuries; for 
instance, fainting from pain is hard to distinguish 
from unconsciousness caused by a head injury. 

• Keep the patient prone, unless associated injuries 
dictate otherwise. Treat him for shock with due 
regard for associated injuries. 

• Do not let the victim eat, since he will probably 
need emergency surgery. His lips may be moistened 
with a clean wet cloth or gauze. 

• Give no medication by mouth. 

• For severe pain, inject one syrette (16 mg) of 
morphine or an equivalent analgesic, and send with 
the patient a report of the medication, dose, and time 
given. Be wary of giving sedatives if there is an 
associated head injury. 

• Refer the victim immediately for emergency 
surgical consultation. 

• Transport the victim by Utter. 

• Have someone stay with the victim during 
emergency treatment and transport to protect his 
airway if vomiting or unconsciousness occurs. 

• Do not apply hot soaks, or attempt to drain or 
squeeze injected material from the wound. These 
procedures are ineffective and can cause more tissue 
damage. 

• Report all grease gun/paint sprayer type injuries 
on MED 6260-1 or by letter report (MED 6260-4) to 
BUMED Code 55.— BUMED Instruction 6260.20 of 
20 January 1976. 

Reporting alcohol treatment and rehabilitation 

Instructions for reporting information on Navy 
alcohol treatment and rehabilitation programs have 
been revised. Each report quarter, naval medical 
facilities shall submit to regional medical centers 
MED 6300-7 on form NAVMED 6300/10 (revised 
January 1976). Reports should include information 
on all patients treated or rehabilitated for alcohol 
abuse. Regional medical centers should submit con- 
solidated regional reports to the Naval Medical Data 
Services Center. Nonregionalized commands should 
send reports directly to Naval Medical Data Services 



Center. Reports must be postmarked by 2400 of the 
fifth working day after the end of the report quarter. 
Forward to: Commanding Officer, Naval Medical 
Data Services Center, National Naval Medical 
Center, Bethesda, Maryland 20014. -BUMED In- 
struction 6330.2 of 5 February 1976. 

Tri-Service Policy on Cosmetic Surgery 

The three military medical services have adopted 
this policy concerning cosmetic surgery: 

As defined by the American Medical Association, 
cosmetic surgery is surgery done to revise or change 
the texture, configuration, or relationship of contigu- 
ous structures of any feature of the human body 
which would be considered by the average prudent 
observer to be within the broad range of "normal" 
and acceptable variation for age and ethnic origin, 
and which is performed for a condition judged by 
competent medical opinion to be without potential 
for jeopardy to physical or mental health. 

Certain cosmetic procedures are a necessary part 
of training and retention of skills to meet the require- 
ments of certification and recertification. Insofar as 
they meet minimum requirements and serve to 
improve the skills and techniques needed for recon- 
structive surgery, cosmetic procedures may be done 
as low priority surgery when time and space are 
available. 

Cosmetic facial rhytidectomies (face lifts) shall be 
a part of all training programs required by certifying 
boards. Cosmetic augmentation mammaplasties will 
be done only by properly credentialed surgeons and 
residents within surgical training programs to meet 
the requirements of certifying boards.— BUMED 
Instruction 6460.8 of 19 February 1976. 

Participation in Regional Medical Programs 

Commanding officers of naval medical facilities 
are encouraged to participate in civilian regional 
medical programs, provided such participation does 
not interfere with military responsibilities. They may 
help regional medical programs in research, 
training, and continuing education efforts, for 
example, as well as patient care demonstrations and 
related activities. Normally this help will not include 
patients otherwise ineligible for military care, con- 
ducting research irrelevant to Navy needs, direct 
fund expenditure, or sharing naval medical equip- 
ment. There should be no significant commitment of 
naval resources without prior BUMED approval. 

Currently, regional medical programs exist to 
combat heart and kidney disease, cancer, and stroke. 
—BUMED Instruction 5700. 2A of 10 March 1976. 



20 



U.S. Navy Medicine 



Clinical Notes 



Propranolol in Migraine Prophylaxis 



LCDR Russell C. Packard, MC, USN 



The pathogenesis of migraine is not completely 
known. The role of vasoconstriction and vasodilation 
seems well established, but the roles of vasoactive 
amines, humeral factors, and the possible effects of 
changes in membrane permeability in capillary 
vessels, remain mostly enigmatic. Thus, there is no 
strict rationale for using propranolol in migraine 
prophylaxis. 

Some of the effects of beta-receptor antagonists 
may, however, explain propranolol's ability to 
prevent attacks: 

• The vasoconstrictor effect may inhibit extra- 
cranial, reactive vasodilation in the headache phase. 

• The local anesthetic, membrane-stabilizing effect 
may reduce both the pain caused by the vasodilation 
and the secondary pericapillary edema. 

• Reduction in the glycogenolysis and glycolysis in 
the brain (1) may result in reduction of the rate of 
vasoactive amines. 

Several studies {2,3) have reported propranolol to 
be more effective than placebo in migraine prophy- 
laxis; but at least two other studies {4,5) using other 
B -blocking agents have shown little or no effect. The 
effectiveness of the different beta-receptor blocking 
agents in treating migraine may therefore vary. 

Patient selection is important. Specifically, pa- 
tients with heart failure, asthma, and heart block 
must not be treated with propranolol. The optimal 
antimigraine dose of propranolol is not known; how- 
ever, there is a wide range in oral dosage require- 
ment among different persons due to difference in 
receptor sensitivity or to pharmacokinetic factors (6). 
It is customary to build the dose up gradually from 40 
mg. daily (in divided doses) to 160 mg. daily. The 
drug should be used for at least three or four weeks 
to assure an adequate trial. The decision to use 
propranolol for migraine prophylaxis depends upon 
the preference of the individual physician, but such 
factors as a poor response to the usual remedies 
(such as ergotamine preparations), or loss of work 

LCDR Packard is a resident on the Neurology Sendee, National 
Naval Medical Center, Bethesda, Maryland 20014. 



because of migraine headache seem adequate indi- 
cations. 

Side effects of propranolol are minor, the most 
common being general fatigue and lethargy. In 
insulin-dependent diabetic patients, warning symp- 
toms of impending hypoglycemia may be obscured. 
Withdrawal of the drug should be carried out by 
gradually tapering the dose over a two-week period. 

REFERENCES 

1. Estler CJ, Ammon HPT: Antagonistic effects of dopa and 
propranolol on brain glycogen. J Pharmacol Exp Ther 22: 146-147, 
1970. 

2. Weber RB, Reinmuth OM: The treatment of migraine with 
propranolol. Neurology 22:366-369, 1972. 

3. Malvea BP, Gwon N, Graham JR: Propranolol prophylaxis 
of migraine. Headache 12:163-168, 1973. 

4. Anthony M, Lance JW, Somerville B: A comparative trial 
of prindolol, clonidine, and carbamazepine in the internal therapy 
of migraine. Med J Aust 1:1343-1346, 1972. 

5. Ekbom U: Alpronolol for migraine prophylaxis. Headache 
15:129-132, 1975. 

6. Shand DG: Propranolol. N Engl J Med 293:280-285, 1975. 



I 

DON'T MISS 

Educating Postmyocardial 
Infarction Patients 

Naval health researchers have developed a ques- 
tionnaire to evaluate the knowledge postmyocar- 
dial infarction patients have about their disease, 
its psychological effects, emergency treatment, diet 
and smoking adjustments, physical activity, and 
problems to expect on returning to home and work. 
CDR Richard H. Rahe, MC, USNR, Cynthia Scalzi, 
M.N., and Kenneth Shine, M.D. report on the ques- 
tionnaire in Heart and Lung 4(5): 759-766, Sep-Oct 
1975. 

Copies are available from Naval Health Research 
Center, San Diego, California 92152; ask for Report 
No. 74-43. 



Volume 67, June 1976 



21 



Professional 



Human Energy Requirements: A Simple Tool for 
Assessment in a Weight Control Program 



LT Steven R. Lamar, W1SC, USN 



The Navy has recently paid con- 
siderable attention to weight con- 
trol, physical fitness, and the ap- 
pearance of naval personnel 
(1,2,3,4). The Secretary of the Navy 
has directed commanding officers to 
identify overweight men and 
women, and to institute prevention 
and treatment programs; medical 
officers have been directed to pay 
particular attention to weight dur- 
ing physical examinations, and to 
help commands treat overweight 
personnel. The Marine Corps, too, 
has started a strict weight control 
program, with a lower maximum 
weight standard for active-duty per- 
sonnel (5). Because of the impetus 
from high command levels and in- 
creasing evidence relating obesity 
to chronic diseases, many medical 
commands need guidance on how to 
implement weight control pro- 
grams. 

In "Energy Metabolism and 
Weight Control" (6), I dealt with 
the theoretical aspects of human 
energy balance, pointing out that 
the body needs energy for four 
major activities: basal metabolism, 
muscular activity, tissue growth and 
repair, and specific dynamic action 
(the energy needed to process 
food). For weight loss to occur, the 
energy expended for these func- 
tions must exceed dietary energy 

LT Lamar is head of the Clinical Nutrition 
Branch, Food Management Service, Naval 
Regional Medical Center, Camp Pendleton, 
California 92055. At the time he wrote this 
article, he was head of the Clinical Nutrition 
Branch, Food Management Service, National 
Naval Medical Center. 



(calorie) intake: the dieter must in- 
crease physical activity, decrease 
food intake, or do both. 

Controlled-calorie diets and pro- 
gressively demanding exercise are 
routinely prescribed for weight 
reduction. But before one can 
recommend effective diet and exer- 
cise programs, one must know the 
patient's energy expenditure, calo- 
ric intake, and energy required to 
maintain present weight. 

This paper presents a method for 
assessing metabolic, activity and 
dietary needs — a method recom- 
mended by physicians, dietitians, 
and clinical counselors who treat 
overweight patients. Although a 
complete weight control program 
should meet the patient's individual 
needs, the following guidelines can 
be used in the initial screening and 
work- up of all overweight men and 
women. The work-up determines 
calories required for basal metabo- 
lism, calories needed for muscular 
activity, total energy requirement to 



maintain present weight, present 
caloric intake, and an appropriate 
diet and exercise regimen based on 
the preceding data. 

OBESITY WORK-UP 

The first step in the obesity work- 
up is to acquire preliminary and 
body weight data. A fictional pa- 
tient's data is recorded in Figures 1 
and 2. 

To determine the energy needed 
to maintain present body weight, 
calories required for basal metabo- 
lism and muscular activity are com- 
puted, along with an estimate of 
total energy requirement (Figure 3). 

Energy used for muscular activity 
is determined by recording a pa- 
tient's activities during a typical day 
(Figure 311). The patient may record 
his activities for 24 hours, or his 
clinical counselor may write the 
record after interviewing the pa- 
tient. All similar activities should be 
grouped together, with additional 



Name: John Doe Social security number: 000-00-0000 Date: S Mar 1976 

10 inches 



Age: 



25 



Sex: 



M 



Height: 



feet 



Present weight: 222 



lbs 



FIGURE 1. Preliminary Data 



Frame: Medium Desirable weight: 146 to 160 lbs {Table I) 

Maximum weight. Marine Corps and Navy aviation personnel standard: 192 lbs 
(Table III 

Recommended weight loss: 30 lbs 



FIGURE 2. Body Weight Data 



22 



U.S. Navy Medicine 



activities added as needed (see 
Table V). The clinical counselor, 
rather than the patient, should 
make final calculations. 

We can now use the energy 
requirements for basal metabolism 
and muscular activity to estimate 
the average energy needed each 
day to maintain present body 
weight (Figure 3III). This estimate 
is adjusted for the lower basal 
metabolism rate during sleep and 
for the influence of specific dynamic 
action. 

To determine present caloric in- 
take, the patient should keep a 
3-day (72-hour) record of food in- 
take, specifying what and how much 
he ate, with a general description of 
ingredients (such as in casseroles 
and salads). The patient should 
record typical days, and should not 
change his eating habits to improve 
the evaluation. The purpose of col- 
lecting a dietary history is not to see 
how good the prospective dieter can 
be, but to gauge his real dietary 
habits, from which a reasonable 
assessment of his energy intake can 
be made. Total caloric intake for 
each of the 3 days is determined, 
and the average intake recorded 
(Figure 4, line B), Accurate caloric 
data on foods can be obtained from 
"Food Values of Portions Com- 
monly Used" (11). 



RECOMMENDED DIET PLAN 

It is now possible to recommend a 
realistic diet and exercise program. 
By completing Figure 4, the patient 
and clinical counselor can predict 
the anticipated rate of weight loss 
and the time required to reach the 
prescribed weight goal. The recom- 
mended safe weight loss rate of 2 
pounds per week (12) can be 
achieved with a daily deficit of 1,000 
calories. For example, our hypo- 
thetical patient, John Doe, requires 
3,605 calories per day to maintain 
his present body weight, but is con- 
suming 3,800 calories. Since we 
want him to lose 2 pounds per week, 
we recommend a daily intake of 
2,600 calories (some 1,200 calories 



I. Calories Required for Basal Metabolism 



A) Height in centimeters (inches x 2.54) 

B) Weight in kilograms (lbs -H 2.2) 

C) Surface area in square meters 
(determine from Table III) 

D) Calories per square meter per day 
(determine from Table IV) 

E) Calories required for basal metabolism 
(multiply C x D) 



177.8 

100.9 

2.2 

921.6 



2028 

(Record in Figure 3, 
Section III, line A) 



II. Calories Required for Muscular Activity: 24-Hour Activity Record 



Activity 



Calories per Energy cost 

Hours spent kg per hour Weight (time x cal/kg/ 
inactivity (Table V] (kg) hr x weight) 



Lying still, awake 0.5 

Dressing and undressing 1.0 

Standing 4.5 



0.1 


100.9 


5 


0.7 


100.9 


71 


0.6 


100.9 


272 



Sitting, writing, 
reading 


eating, 


5.0 


Walking, light exercise 


1.5 


Driving car 




1.0 


Playing cards 




0.75 


Football 




0.5 


Walking rapidly 




0.5 


Typing rapidly 




0.75 


Sleeping 




Record ti 



Calories required for muscular activity 



0.4 100.9 202 

1.4 100.9 212 

0.9 100.9 91 

0.5 100.9 38 

6.8 100.9 343 

3.4 100.9 172 

1.0 100.9 76 
ne spent sleeping in Section III, line D 

1482 

(Record in Section 
III, line B) 



III. Estimate of Total Energy Requirement 



A) Calories required for basal metabolism 
(from Section I, line E) 

B) Calories required for muscular activity 
(from Section II) 

CI Total calories for basal + activity 
(block A + block B) 

D) Time spent sleeping per day: 8 hrs 

( S hrs sleep) x (weight 100,9 kg) x (0.1) 

E) Calories required for specific dynamic action 
of food: block C x 5% 

F) Total energy requirement 
(block C - block D + block E) 



2028 
1482 
3510 

81 

176 
3605 calories 



FIGURE 3. Estimate of Total Energy Requirement 



Volume 67, June 1976 



23 



FIGURE 4. Diet Plan and Projected Weight Loss Data 



A) Total energy requirement 
(from Figure 3111, line F) 

B) Present average caloric intake 

CI Recommended intake for weight loss 

Dl Additional recommended dietary 
modifications 



El Recommended weight loss 

F} Anticipated rate of weight loss 

G) Anticipated time required to achieve 
weight goal 



3605 calories/day 

3800 calories/day 

2600 ca!ories/day 

4 gm sodium/day 
less than 300 mg 
cholesterol/day 
P/S ratio =2:1* 

30 lbs 

2 lbs/ week 

1 5 weeks 



*P/S ratio = polyunsaturated fatty acids -r- saturated fatty 
acids. 



TABLE II. Weight Standards for Marine Corps and 
Navy Aviation Personnel {5,8} 



Men 



Height (inches) 
64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 

Weight (lbs) 
Minimum 

105 106 107 111 115 119 123 127 131 135 139 143 147 151 153 

Maximum 

160 165 170 175 181 186 192 197 203 209 214 219 225 230 235 



Women 

Height (inches) 
58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 

Weight (lbs) 
Minimum 

90 92 94 96 98 100 102 104 106 109 112 115 118 122 125 

Maximum 

121 123 125 127 129 135 136 140 144 147 152 158 162 168 171 



TABLE I. Desirable Weight in Pounds According to 
Frame (7) (in indoor clothing) 



TABLE III. Chart for Determining Body Surface Area (9) 





Desirable Weight for Men Age 


25 and Over 


t 


Height with Shoes 








(1- 


nch heels) 








Feet 


Inches 


Frame 


Frame 


Frame 


5 


2 


112-120 


118-129 


126-141 


5 


3 


115-123 


121-133 


129-144 


5 


4 


118-126 


124-136 


132-148 


5 


5 


121-129 


127-139 


135-152 


5 


6 


1 24-1 33 


130-143 


138-156 


5 


7 


128-137 


134-147 


142-161 


5 


8 


132-141 


138-152 


147-166 


5 


9 


136-145 


142-156 


151-170 


5 


10 


140-150 


146-160 


155-174 


5 


11 


144-154 


150-165 


159-179 


6 





148-158 


1 54-1 70 


164-184 


6 


1 


1 52-1 62 


1 58-1 75 


168-189 


6 


2 


156-167 


162-180 


173-194 


6 


3 


160-171 


167-185 


178-199 


6 


4 


164-175 


172-190 


182-204 


*For 


nude weight, deduct 5 to 7 lbs. 








Desirable Weights 


for Women Age 25 and Over* 


Height with Shoes 








(2- 


nch heels) 


Small 


Medium 


Large 


Feet 


Inches 


Frame 


Frame 


Frame 


4 


10 


92- 98 


96-107 


104-119 


4 


11 


94-101 


98-110 


106-122 


5 





96-104 


101-113 


109-125 


5 


1 


99-107 


1 04-1 1 6 


112-128 


5 


2 


102-110 


107-119 


115-131 


5 


3 


105-113 


110-122 


118-134 


5 


4 


108-116 


113-126 


121-138 


5 


5 


111-119 


116-130 


125-142 


5 


6 


114-123 


120-135 


129-146 


5 


7 


118-127 


1 24-1 39 


133-150 


5 


8 


122-131 


128-143 


137-154 


5 


9 


126-135 


132-147 


141-158 


5 


10 


130-140 


136-151 


145-163 


5 


11 


134-144 


140-155 


149-168 


6 





138-148 


144-159 


153-173 



To determine your body surface area, locate your height on the left axis 
and your present weight on the right axis. Draw a straight line between 
these points. The value where this line crosses the center axis is your 
body surface area in square meters. 

Weight 



Height 

: 200 
--I90 



8" 

6'6" 

4" 

2" 

6'0"— t 
.-... - E- 1B0 
10" -z~ 



"For nude weight, deduct 2 to 4 lbs. 



4'0" — 


H20 


10" - 






r-U5 


8" - 






— 110 


3'6" — 






r-105 










4" - 






-100 






2" - 






-95 






3'0"— 


. 




-90 








■ 




t 85 



8" -: 

5'6"J- ,7 ° 
■165 
4" -J 
--160 

2 "i, 55 

| 10"-: g 

- --145 | 

•o 8" - : E 

--140 " 

I 4 ' 6 "iL.35 C 

4" ~ : 

"-130 

r :i- U5 



2.9 -f 
2.8-= 
2.7 1 
2.6 4 
2.5-= 
2.4-1 
2.3 4 

■ — m-i- 

2.1 -j 

2.0 -I 

1.9 H 

e 1.8 H 

I I7 J 

5 1.6 H 
3 = 

6 ' 5 - 

jj Ml 

< 

8 \3-. 

I 1.2 -: 

ii -i 

1.0- 

0.9 

0,8- 

0.7- 



0.6- 



^^160 

320 ^L 1+0 
3003E 

2BO-H 30 

26oir m 

J.10 ■ § ■ 10 9- 

-^95 
200-^90 
190-iLg 5 

I80-|_ EO 

"Hi- 75 

160 1L 70 
150-EE 

■ 140 Jr 65 

1 130-ir 60 
£ 120-jr 55 

110-=r50 
100-EJ-45 

90-iL40 



70 



--30 



60-- 



-25 



50- 



40- 



--20 



1-15 



24 



U.S. Navy Medicine 



TABLE IV. Basal Metabolism 
Standard (10) 

To determine your energy requirement 
(calories) per body surface area, select the 
caloric value which corresponds to your age 
and sex and multiply by square meter de- 
termined in Table III, 



TABLE V. Energy Cost of 
Activities (10) 





Calories per square 


meter per day 


Age 


Males 


Females 


5 


1351.2 


1272.0 


6 


1296.0 


1228.8 


7 


1255.2 


1192.8 


8 


1219.2 


1152.0 


9 


1188.0 


1108.8 


10 


1144.8 


1077.6 


11 


1116.0 


1044.0 


12 


1087.2 


1008.0 


13 


1 068.0 


972.0 


14 


1051.2 


940.8 


15 


1029.6 


919.2 


16 


1008.0 


892.8 


17 


996.0 


873.6 


18 


979.2 


859.2 


19 


972.0 


849.6 


20 


957.6 


847.2 


21 


948.0 


844.8 


22 


940.8 


844.8 


23 


936.0 


844.8 


24 


928.8 


842.4 


25 


921.6 


842.4 


26 


916.8 


840.0 


27 


912.0 


840.0 


28 


907.2 


840.0 


29 


904.8 


840.0 


30 


902.4 


840.0 


31 


897.6 


840.0 


32 


892.8 


837.6 


33 


890.4 


837.6 


34 


888.0 


837.6 


35 


885.6 


835.2 


36 


883.2 


832.8 


37 


880,8 


830.4 


38 


880.8 


828.0 


39 


878.4 


825.6 


40-44 


873.6 


818.4 


45-49 


868.8 


811.2 


50-54 


859.2 


794.4 


55-59 


842.4 


787.2 


60-64 


828.0 


768.0 


65-69 


804.0 


758.4 


70-74 


784.8 


746.4 


75+ 


763.2 





(Exclusive of basal metabolism 


and influ- 


ence of foods) 




Cal 


ories per kg 


Activity 


per hr 


Bedmaking 


3.0 


Bicycling (high speed) 


7.6 


Bicycling (moderate speed) 


2.5 


Boxing 


11.4 


Carpentry Iheavy) 


2.3 


Cello playing 


1,3 


Cleaning windows 


2.6 


Crocheting 


0.4 


Dancing, moderately active 


3.8 


Dishwashing 


1.0 


Dressing and undressing 


0.7 


Driving car 


0.9 


Eating 


0.4 


Exercise 




Very light 


0.9 


Light 


1.4 


Moderate 


3.1 


Severe 


5.4 


Very severe 


7.6 


Fencing 


7.3 


Football 


6,8 


Gardening, weeding 


3.9 


Golf 


1.5 


Horseback riding (trot) 


4.3 


Ironing (5 lb iron) 


1.0 


Knitting sweater 


0.7 


Laboratory work 


2.1 


Laundry, light 


1.3 


Lying still, awake 


0.1 


Office work, standing 


0.6 


Painting furniture 


1.5 


Paring potatoes 


0.6 


Playing cards 


0.5 


Playing ping pong 


4.4 


Piano playing 


0.8 


Reading aloud 


0.4 


Rowing 


9.8 


Rowing in race 


16.0 


Running 


7.0 


Sawing wood 


5.7 


Sewing, hand 


0.4 


Sewing, foot-driven machine 


0.6 


Sewing, electric machine 


0.4 


Singing in loud voice 


0.8 


Sitting quietly 


0.4 


Skating 


3.5 


Skiing (moderate speed) 


10.3 


Standing at attention 


0.6 


Standing relaxed 


0.5 


Sweeping with broom 


1.4 


Sweeping with carpet sweeper 


1.6 


Sweeping with vacuum cleaner 


2.7 


Swimming |2 miles per hr) 


7.9 


Tailoring 


0.9 


Tennis 


5.0 


Typing, rapidly 


1.0 


Typing, electric typewriter 


0.5 


Violin playing 


0,6 


Walking (3 miles per hr) 


2.0 


Walking (4 miles per hr) 


3.4 


Walking at high speed 




(5 miles per hr) 


8,3 


Walking down stairs 


* 


Walking up stairs 


* H- 


Washing floors 


1.2 


Writing 


0.4 



Allow 0.012 calorie per kilogram for an 
ordinary staircase with 15 steps, without 
regard to time. 
*Allow 0.036 calorie per kilogram for an 
ordinary staircase with 15 steps, without 
regard to time. 



Volume 67, June 1976 



less than his actual intake). At this 
rate, Mr. Doe should achieve his 
recommended weight loss of 30 
pounds in 15 weeks. Since a 
physical examination showed that 
Mr. Doe has high blood pressure 
and an elevated serum cholesterol 
level (Type Ha hyperlipoprotein- 
emia), his 2,600 calorie diet will also 
include less sodium, cholesterol, 
and saturated fat. 

Medical commands responsible 
for initial screening and work-up of 
obese patients should find this 
energy assessment method a useful 
clinical tool to determine the pre- 
liminary data needed to formulate 
effective diet and exercise plans. 

REFERENCES 

1. OPNAV Instruction 1550.22B of 23 
Apr 1973: General military training. Office of 
the Chief of Naval Operations, Department 
of the Navy, Washington, D.C. 

2. BUPERS Memorandum of 13 Jul 1973: 
Weight control and physical appearance of 
Naval Personnel. Bureau of Naval Personnel, 
Washington, D.C. 

3. BUMED Instruction 6110.10 of 24 Jan 
1974: Weight control. Bureau of Medicine 
and Surgery, Department of the Navy, 
Washington, D.C. 

4. BUPERS Memorandum of 30 Nov 
1974: Weight control and physical appear- 
ance of Navy Personnel. Bureau of Naval 
Personnel, Washington, D.C. 

5. Marine Corps Order 6100.3G of 23 
Sept 1975: Physical fitness, weight control, 
and military appearance. Headquarters 
Marine Corps, Washington, D.C. 

6. Lamar S: Energy metabolism and 
weight control. U.S. Navy Medicine 63(4): 25- 
34, Apr 1974. 

7. Bondy PK, ed,: Duncan's Diseases of 
Metabolism, 6th ed. Philadelphia: W.B. 
Saunders Co., 1969, p. 1268. 

8. Weight standards for Navy and Ma- 
rine Corps personnel. Manual of the Medical 
Department, Physical Standards, Articles 15- 
17. Bureau of Medicine and Surgery, Depart- 
ment of the Navy, Washington, D.C, 1971. 

9. Boothby W, Berfcson J, Dunn H: 
Studies of the energy metabolism of normal 
individuals: A standard for basal metabo- 
lism, with a nomogram for clinical applica- 
tion. Am J Physiol 116:468-484, 1936, 

10, Chaney M, Ross M: The energy 
balance. In Nutrition, 8th ed. Boston: 
Houghton Mifflin Co., 1971, p. 37. 

11, Church C, Church H: Food Values of 
Portions Commonly Used, 12th ed. Philadel- 
phia: J.B. Lippincott Co., 1975. 

12, Wohl M, Goodhart R: Obesity. In 
Modern Nutrition in Health and Disease, 4th 
ed. Philadelphia: Lea & Febiger, 1968. 



25 



Sublingual Dermoid Cyst: 

Report of a Case 



LCDR M. Bedford Smith, DC, USN 
CAPT B.J. DeVos, DC, USN 



Dermoid cysts of the floor of the mouth are rare, 
comprising only 0.01% of all oral cystic lesions. 
These cysts may be either congenital or acquired. 
The congenital cysts arise from inclusion of ecto- 
derm, with or without dermal appendages, when the 
neural groove is closed; or they result from the co- 
alescence of other epithelial lines of fusion (J). Some 
of the cysts may be formed from remnants of the 
tuberculum impar of His which, together with the 
lateral process from the inner surface of each man- 
dibular arch, form the body of the tongue and the 
floor of the mouth. This inclusion occurs during the 
third and fourth week of intrauterine development 
(2). Acquired dermoid cysts, which comprise less 
than 10% of reported cases, may result from trauma, 
iatrogenesis, or occlusion of hair follicles or seba- 
ceous glands. Of 1,495 cases of dermoid cysts 
studied at the Mayo Clinic between 1910 and 1935, 
only 103 cases occurred in the head and neck; 24 
were in the floor of the mouth, an incidence of only 
1.6%. Fewer than 200 cases of oral dermoid cyst 
have been reported since 1859 (i). 

Dermoid cysts have been classified into three 
groups : 

Epidermoid cyst. A cyst whose epithelial-lined 
wall is derived from epidermis and supporting con- 
nective tissue, and contains no dermal appendages. 

Dermoid cyst. A cyst with a similar epithelial- 
lined cavity, but which contains dermal appendages 
such as hair, hair follicles, sebaceous glands and 
sweat glands in the underlying connective tissue. 

Teratoma. A lesion usually described as contain- 
ing a disorderly arrangement of tissues and organs. 
It has an epithelial-lined cavity as well as 
mesodermal and endodermal elements such as 



LCDR Smith is a postdoctoral fellow in oral surgery and CAPT 
DeVos is an oral surgeon on the staff of the Naval Training Cen- 
ter, Orlando, Florida 32813. 



26 



muscle, intestinal mucosa, respiratory mucosa, 
bone, blood vessels, and dermal appendages (2). 

Mosby, Robertson and Sugg (3) have proposed 
another classification. They would maintain "der- 
moid cyst" as the clinical term, and use the following 
terms for histological examination: 

Simple dermoid cyst of the floor of the mouth 
contains no dermal appendages. 

Compound dermoid cyst of the floor of the mouth 
contains one or more skin appendages. 

Complex dermoid cyst of the floor of the mouth 
contains elements from all three germ layers. 

In this case report, I will use the traditional classi- 
fication most commonly found in published studies. 

SYMPTOMS AND TREATMENT 

The dermoid cyst is rarely seen at birth. It most 
frequently occurs in people aged 15-35 years; there 
is no predilection for sex. The lesion usually appears 
in the midline and may be above (sublingual) or 
below (submental) the mylohyoid muscle. Very 
rarely, the cyst may be located between the medial 
surface of the mandible and the musculature of the 
tongue (J). The weight can vary from one to several 
hundred grams and the capacity from a few to more 
than 1,000 cubic centimeters. Not a fluid sac, the 
lesion is instead filled with a yellowish caseous 
material derived from the cyst wall. When palpated, 
the lesion usually has a doughy texture (2). The 
mucosa overlying the cyst may vary in color from 
normal to yellow depending on the depth of the 
lesion below the mucosa (3) . 

Symptoms may include a slowly enlarging intra- 
oral swelling in the floor of the mouth, which may 
cause displacement of the tongue with resultant dif- 
ficulty in eating, talking and breathing. Extraoral 
swelling resembling a double chin may develop. The 
lesion retains pitting after pressure has been 

U.S. Navy Medicine 



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FIGURE 1. The cystic mass is delivered FIGURE 2. This medium-power photomi- FIGURE 3. High-power photomicrograph 
from the midline of the floor of the mouth. crograph shows a cystic wall lined with of the cyst wall. 

squamous epithelium. 



applied. Sinus tracts, opening either intraorally or 
extraorally, may develop. There is usually no pain 
associated with the lesion unless infection is present 
or the mass exerts pressure on the lingual nerve. The 
most unfavorable sequelae of this lesion are that it 
may undergo malignant change and then metasta- 
size to the lymph nodes. 

A thorough differential diagnosis is essential to 
distinguish the dermoid cyst from several other 
lesions that occur in the midline of the floor of the 
mouth. If the mass is above the mylohyoid, the 
entities to be considered are ranulas, subungual 
abscesses, and benign or malignant tumors of the 
mouth. A mass located below the mylohyoid may be 
confused with blocked submaxillary ducts, a thyro- 
glossal duct cyst, a cystic hygroma, a branchial cleft 
cyst, or submaxillary sialadenitis (1,2). 

One of the most unusual cases of dermoid cyst 
involved a sublingual cyst in a patient who had 
congenital ankyloglossia, which was separated in 
infancy. This patient had what appeared to be two 
distinct dermoid cysts— one sublingual, the other in 
the tip of the tongue— both with protruding hairs. It 
was suggested that the cysts were part of a single 
lesion— a sublingual dermoid cyst that had been the 
cause of the ankyloglossia. 

The dermoid cyst requires surgical excision. The 
lesion is easily removed with blunt dissection unless 
it has been treated with sclerosing solution or is 

Volume 67, June 1976 



infected. A transoral approach is used for sublingual 
cysts; an extraoral approach is recommended for 
submental lesions. 

Diagnostic aspiration of the cyst should be 
avoided, since infection may result that would com- 
plicate an otherwise easy surgical removal. How- 
ever, the lesion should be aspirated at surgery to 
rule out the possibility of angioma, If the lesion is 
already infected, aspiration may be used for tempo- 
rary relief (1,2). 

A complicating factor in removal of the dermoid 
cyst is administration of anesthesia. When the 
tongue is displaced and direct vision of the larynx 
impossible, several methods for administering 
general anesthesia are available if local anesthesia is 
insufficient. The lesion may be decompressed before 
attempting intubation; a catheter may be passed in a 
retrograde fashion through the cricothyroid mem- 
brane into the mouth, with a tracheal tube then 
threaded into the larynx; or a tracheostomy may be 
performed (4). 

CASE REPORT 

An 18-year-old seaman recruit was seen at the Dental Depart- 
ment, Naval Training Center, Orlando, Florida, for routine dental 
examination. A swelling was observed in the midline of the 
anterior floor of the mouth. The patient said the swelling had 
been present as long aa he could remember. It had not increased 
significantly in size in the past several years. 



27 



The past history, family history, and review of systems were 
either negative or noncontributory to the present illness. 

Physical examination revealed a well-developed, well- 
nourished Caucasian male in no obvious distress. Intraoral exam 
revealed a fluctuant, relatively superficial mass measuring ap- 
proximately 3.0 centimeters in diameter in the anterior floor of 
the mouth; the mass was believed to be superficial to the 
genioglossus. The remainder of the physical examination was 
within normal limits. 

Routine laboratory studies on admission revealed an essen- 
tially normal hemogram and urinalysis. A routine serology was 
negative. Chest X-rays showed no abnormalities. 

On 2 October 1975 the patient was taken to the operating room 
for enucleation of the cyst under general anesthesia via nasoen- 
dotracheal tube. No difficulty was encountered during intubation. 
A vertical incision measuring approximately 3.5 centimeters was 
made into the oral mucosa inferior to the tongue and carried 
anteriorly between the caruncles of the submandibular ducts. 
The incision was extended via sharp and blunt dissection to 
expose the cystic mass which was lying between the genioglos- 
sae. The cyst was enucleated via sharp and blunt dissection 
(Figure 1). The cyst ruptured during delivery, and a yellow 
caseous material was found to fill the cavity. The incision was 
closed in layers with polyglycolic acid interrupted sutures. 

The histological examination revealed a cystic wall partially 



lined by squamous epithelium and aggregates of giant cells that 
contained fatty material in their cytoplasm. The lumen of the cyst 
was filled with pinkish keratin material (Figures 2 and 3). The 
changes were consistent with those of a partially ruptured der- 
moid cyst. 

According to the traditional classification, this lesion was 
probably an epidermoid cyst, since it contained no dermal ap- 
pendages. 

Postoperatively the patient progressed satisfactorily; he was 
discharged to duty on 7 October 1975. Follow-up examinations 
revealed satisfactory healing. The sutures were removed on the 
tenth postoperative day. The patient left the training center three 
weeks after surgery and was lost to follow-up. 

REFERENCES 

1. Brown CA, Baker RD: Dermoid cyst: report of a case. J 
Oral Surg 30:55-58, 1972. 

2. Gold BD, Sheinkopf DE, Levy B: Dermoid, epidermoid, 
and teratomatous cysts of the tongue and floor of the mouth. J 
Oral Surg 32:107-111, 1974. 

3. Mosby EL, Robertson GR, Sugg WE: Compound dermoid 
cyst of the floor of the mouth. J Oral Surg 32:601-603, 1974. 

4. Stewart S, Glogoff M, Sherman P: Large sublingual der- 
moid cyst: report of a case. J Oral Surg 31:620-623, 1973. 



Scholars' Scuttlebutt 



It seems as if every one of our subsidy 
students has called or written BUMED 
to complain about recent changes in the 
tax regulation covering their subsidies. 
Frankly, we don't blame you a bit. Per- 
haps we can explain what happened. 

As you know, the Armed Forces 
Health Professions Scholarship Pro- 
gram (AFHPSP) was designed to meet 
the Armed Forces' need for qualified 
physicians, dentists, and other medical 
specialists after the draft ended. Pro- 
gram participants are commissioned as 
Reserve officers on inactive duty while 
in training. During their annual 45 days 
of active duty, they receive grade 0-1 
pay and allowances; for the remainder 
of the year they receive a monthly 
stipend of $400. The Armed Forces pay 
tuition, fees, books, and laboratory 
expenses. All of the foregoing consti- 
tute scholarship benefits. 

On completing training, AFHPSP 
participants are required to serve on 
active duty for a period of time based on 
length of training. 

In a ruling dated 1 August 1973 the 
Internal Revenue Service (IRS) stated 
that scholarship benefits received by 
AFHPSP participants are , not exclud- 
able from gross income as a fellowship 
grant. Department of Defense officials 



immediately protested that the AFHPS 
Program would be less attractive to stu- 
dents if scholarship benefits were in- 
cluded in the participants' gross in- 
come, and that such a policy would 
hamper the Armed Forces' ability to 
recruit medical and dental students. 
Responding to that concern, Congress 
enacted Public Law 93-483 on 26 
October 1974. Under this law, scholar- 
ship benefits for 1973, 1974 and 1975 
were treated as "scholarship" under 
section 117 of the 1974 Internal Revenue 
Code and were excluded from gross in- 
come. No legislation was enacted to ex- 
tend this provision, however, and the 
IRS determined that scholarship bene- 
fits received by AFHPSP participants 
after 1 January 1976 would be treated as 
"compensation" and therefore included 
in gross income. 

DOD then drafted new legislation 
that would amend section 117 of the 
Internal Revenue Code to provide per- 
manent tax exclusion for stipends, tu- 
ition, fees, books, and laboratory ex- 
penses paid on behalf of AFHPSP par- 
ticipants. The proposed legislation was 
submitted to the Office of Management 
and Budget for approval on 22 October 
1975. Because Congress might not con- 
sider this legislation until summer, 



DOD asked the IRS to set a one- year 
moratorium on including AFHPSP 
scholarship benefits in gross income. 
This delay would give Congress suffi- 
cient time to consider and perhaps pass 
the proposed legislation. 

On 19 February 1976, the IRS ruled 
that AFHPSP benefits are not "scholar- 
ships" that can be deducted from gross 
income, because receipt of these bene- 
fits is conditional on performing future 
services. The IRS also said that Con- 
gress had had enough time while P.L. 
93-483 was in effect to review taxation 
of scholarships and fellowships; since 
Congress did not authorize the Treasury 
Department to refrain permanently 
from collecting tax on AFHPSP bene- 
fits, the Secretary of the Treasury says 
he cannot establish the moratorium 
requested by DOD. Therefore, as of 
May 1976, all benefits provided by the 
Armed Forces to AFHPSP students are 
taxable as gross income, effective 1 
January 1976. 

We realize that this tax takes most of 
your stipend each month, and we share 
your concern. However, the Navy has 
no choice but to comply with existing 
IRS regulations. We have every hope 
that Congress will soon correct this in- 
equity through legislative action. 



28 



U.S. Navy Medicine 



BUMED SITREP 



NEW CO's . . . Medical Service Corps 
officers are being assigned as com- 
manding officers of five more medical 
facilities. The new CO's are: CAPT 
Eugene M. Bryant, Jr. (NH Cherry 
Point); CAPT John D. Pruirt (NH 
Annapolis); CAPT Rodger F. Schindele 
(NH Quantico); CAPT Jay C. Smout 
(NH Whidbey Island); and CDR James 
R. Erie (NH Patuxent River). These as- 
signments help relieve medical officers 
of administrative duties, freeing them 
for direct patient care. 

MANAGEMENT BY OBJECTIVES . . . 
LCDR R.L. DeVault (MSC) has been 
named special assistant to the Surgeon 
General (BUMED Code 0014) as pro- 
gram manager for Management by 
Objectives (MBO). 

Ten objectives have been promul- 
gated within BUMED. The first four, 
along with architectural plans and 
action plans, originated from the CNO- 
appointed Navy Health Care Review 
Committee and constitute the CNO 
direction for the Navy health care 
system of the future. Briefly these 
objectives are: 

■ To give the highest priority to health 
care support of the operating forces. 

• To establish and conduct a require- 
ments-based professional education and 
training program. 

• With Chief, BUPERS and Deputy 
CNO (Manpower), to issue a joint for- 
mal guidance plan on management of 
health care and personnel, including 
procedures to measure personnel utili- 
zation through selected monitoring 
factors. 

• Through identification and evalua- 
tion, to minimize the effects of epidemi- 
ological, environmental, occupational 
and operational health risks. 

These objectives are supplemented 
by six broad objectives drawn up by the 
Surgeon General's MBO Committee: 

• To provide full preventive and cura- 
tive medical and dental service to mem- 
bers of the active-duty naval establish- 
ment. 

• To provide all possible health care to 
other eligible beneficiaries in the direct 
care system. 

• To maintain a trained and experi- 
enced all-volunteer professional force. 

• To design and maintain modern facili- 
ties and materiel. 

• To operate the direct health services 



system according to accepted principles 
for maximum effectiveness, efficiency, 
quality and accountability. 
• To conduct military medical research. 
BUMED codes are developing de- 
tailed action plans to accomplish the 
four CNO-originated objectives. In sup- 
port of the six BUMED-originated 
objectives, codes are developing key 
result areas, specific goals and indica- 
tors, and action plans. 

FLYING FAMILY PHYSICIANS . . . 

Medical officers trained in both aero- 
space medicine and family practice are 
needed to staff Patrol Wing II squad- 
rons at Naval Air Station Jacksonville, 
Florida. The goal: to form a group of 
medical officers who can support the 
fleet during deployments and care for 
aviation personnel and their families at 
the home naval air station. One billet is 
filled; another opens this summer, and 
two more are planned as more dually- 
trained medical officers become avail- 
able. Interested officers should contact 
BUMED Code 511. 



MANPOWER CLASSIFICATION . . . 

Naval officer billet classifications 
(NOBC), subspecialty codes, and addi- 
tional qualification (AQD) codes for 
Medical Department officers have been 
revamped. New classifications will be 
promulgated as Change 1 to the Navy 
Officer Manpower and Personnel Clas- 
sifications Manual (NAVPERS 15839C), 
Here's a preview: 

• Many NOBC titles will be revised or 
deleted. 

• NOBCs will provide functional de- 
scriptions of billet requirements in view 
of changes incorporated in other classi- 
fication systems. 

• The Navy subspecialty system will be 
expanded to define the subspecialty. 
The education/training level within the 
subspecialty will be indicated by a suffix 
letter. 

• AQD classifications will include only 
the qualifications generally attained by 
Navy functional training. 

In coordination with BUMED as 
designator adviser, CNO will implement 
revised classifications for all billets with 
210X, 220X, 230X, 290X, and 754X 
designators. Implementation of the 
revamped classifications will be com- 
pleted during calendar year 1976. 



SILVER RECOVERY ... The Silver 
Recovery Program is attracting the in- 
terest of the Naval Audit Service. 
Defense Supply Agency has assumed 
responsibility for the Precious Metals 
Recovery Program, and will fund for all 
associated equipment and most 
charges. The Naval Medical Materiel 
Support Command is program manager 
for BUMED. Questions or requests for 
assistance concerning the program 
should be directed to NAVMEDMAT- 
SUPPCOM Code 25; Autovon 443-8737 
or commercial (215)755-8737. 

FINANCIAL MANAGEMENT ... The 

Navy is developing changes in its finan- 
cial management information programs 
that will have a major impact on the 
Medical Department. The Uniform Gen- 
eral Ledger Accounting System 
(UGLAS), to be implemented 1 October 
1976, completely revises the current ac- 
counting system. The Uniform Manage- 
ment Reports (UMR) system is de- 
signed to provide accurate, more timely 
reports, and to be more responsive to 
management needs. The Integrated 
Disbursements and Accounting (IDA) 
system will be a nationwide telecom- 
munication system of disbursing and 
accounting; it will improve the entry of 
data into the accounting system, and 
incorporate the disbursing process as an 
integral function of the system. Infor- 
mation regarding these changes will be 
sent to field activities, with implement- 
ing instructions, soon after it is received 
at BUMED. 

ZERO BACKLOG . . . NRMC San 

Diego, for what is believed to be the 
first time in its history, has achieved a 
zero backlog in medical transcription. 
Narrative summaries and medical 
boards are now transcribed and ready 
for signature on the same day or with- 
in one day of their dictation. The CO, 
his fine staff, and their COMPU-TEXT 
System deserve sincere congratula- 
tions. 

LENGTH OF STAY ... The Systems 
Engineering Division (BUMED Code 
023) has developed a new model for 
assessing length of patient stay at naval 
hospitals. The model compares actual 
length of stay in Navy hospitals with the 
mean length of stay at 1,801 civilian 
hospitals during 1974 (the objective 
standard). It also identifies illnesses 
that cause significantly long patient 
stays, allowing naval hospitals to moni- 
tor these diagnoses more closely. 



Volume 67, June 1976 



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